Basic Information
| Provider Information | |||||||||
| NPI: | 1962711200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAMKISSOON | ||||||||
| FirstName: | RAMNAUTH | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2129 | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797602129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326406700 | ||||||||
| FaxNumber: | 4326404700 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 JBS PKWY | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797628126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326406700 | ||||||||
| FaxNumber: | 4326404700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2010 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA06886 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 280678802 | 05 | TX | MEDICAID |