Basic Information
| Provider Information | |||||||||
| NPI: | 1679958383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELTRAN | ||||||||
| FirstName: | JODIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9398 VISCOUNT BLVD | ||||||||
| Address2: | STE C | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799258056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155941033 | ||||||||
| FaxNumber: | 9155941263 | ||||||||
| Practice Location | |||||||||
| Address1: | 9398 VISCOUNT BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799258056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155941033 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2015 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA09802 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 353084201 | 05 | TX | MEDICAID | 451648YLPS | 01 | TX | WELLMED PTAN | OTHER |