Basic Information
| Provider Information | |||||||||
| NPI: | 1902896863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKINLEY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 OLD BULLARD RD, | ||||||||
| Address2: | PMB 56 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757034340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033124004 | ||||||||
| FaxNumber: | 8882428720 | ||||||||
| Practice Location | |||||||||
| Address1: | 1814 ROSELAND BLVD | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757014234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035268754 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 06/01/2011 | ||||||||
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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 | 207QS0010X | H4539 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 123027808 | 05 | TX | MEDICAID |