Basic Information
Provider Information | |||||||||
NPI: | 1649721366 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TIJERINO | ||||||||
FirstName: | MAX | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 846098 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752846098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9033246400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 703 S FLEISHEL AVE | ||||||||
Address2: | STE 5000 | ||||||||
City: | TYLER | ||||||||
State: | TX | ||||||||
PostalCode: | 757012015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9035252992 | ||||||||
FaxNumber: | 9035252685 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2016 | ||||||||
LastUpdateDate: | 02/10/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   | AL | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 363A00000X | PA10936 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 75-2616977-039 | 01 | TX | TRICARE | OTHER | 75-2616977-123 | 01 | TX | TRICARE | OTHER | 88117MA | 01 | TX | BCBS | OTHER | 365425301 | 05 | TX |   | MEDICAID | P01762498 | 01 | TX | RAIL ROAD MEDICARE | OTHER |