Basic Information
| Provider Information | |||||||||
| NPI: | 1689244675 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NINAN | ||||||||
| FirstName: | JAISON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 MEDICAL CENTER DR | ||||||||
| Address2: | STE C | ||||||||
| City: | DECATUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762343844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406262110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 MEDICAL CENTER DR STE C | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762343844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406262110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2021 | ||||||||
| LastUpdateDate: | 09/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA14759 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.