Basic Information
Provider Information | |||||||||
NPI: | 1750544367 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST TEXAS MEDICAL ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3605 EXECUTIVE DR | ||||||||
Address2: |   | ||||||||
City: | SAN ANGELO | ||||||||
State: | TX | ||||||||
PostalCode: | 769046884 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3259499555 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3605 EXECUTIVE DR | ||||||||
Address2: |   | ||||||||
City: | SAN ANGELO | ||||||||
State: | TX | ||||||||
PostalCode: | 76904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3259499555 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2008 | ||||||||
LastUpdateDate: | 12/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCMAHON | ||||||||
AuthorizedOfficialFirstName: | TOMMY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3259499555 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WEST TEXAS MEDICAL ASSOCIATES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 135031601 | 05 | TX |   | MEDICAID |