Basic Information
| Provider Information | |||||||||
| NPI: | 1770834947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEONG | ||||||||
| FirstName: | MYOUNGSOOK | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 FM 300 | ||||||||
| Address2: | |||||||||
| City: | LEVELLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793366235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8068947842 | ||||||||
| FaxNumber: | 8068943378 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 S GREGG ST | ||||||||
| Address2: | |||||||||
| City: | BIG SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797204325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4325174557 | ||||||||
| FaxNumber: | 4325174561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2012 | ||||||||
| LastUpdateDate: | 11/20/2014 | ||||||||
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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 | 363LA2200X | 788220 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 788220 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 281971602 | 05 | TX | MEDICAID |