Basic Information
| Provider Information | |||||||||
| NPI: | 1770687774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIRKLAND | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 WALLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064149559 | ||||||||
| FaxNumber: | 8063513765 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 S COULTER ST | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064149559 | ||||||||
| FaxNumber: | 8063513765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | H2509 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200100710A | 05 | OK | MEDICAID | 135452409 | 05 | TX | MEDICAID | 49759370 | 05 | NM | MEDICAID | 135452411 | 05 | TX | MEDICAID |