Basic Information
| Provider Information | |||||||||
| NPI: | 1790073435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NASH | ||||||||
| FirstName: | RONNIE | ||||||||
| MiddleName: | DALE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20208 STATE HIGHWAY 155 S | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757625600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038256222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2011 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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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 | 363AM0700X | PA07329 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 75-2616977-028 | 01 | TX | TRICARE | OTHER | 851N93 | 01 | TX | BCBS | OTHER | 75-2616977-001 | 01 | TX | TRICARE | OTHER | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 752616977001 | 01 | TX | TRICARE | OTHER | 752616977002 | 01 | TX | TRICARE | OTHER | 283652001 | 05 | TX | MEDICAID | 75-2616977-041 | 01 | TX | TRICARE | OTHER |