Basic Information
| Provider Information | |||||||||
| NPI: | 1972577419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANNING | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1720 S BECKHAM AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757014464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035972002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207V00000X | J6425 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1972577419 | 05 | TX | MEDICAID | 123074 | 01 | TX | SUPERIOR HEALTH CHIPS | OTHER | 75-2616977-136 | 01 | TX | TRICARE | OTHER | 129809306 | 05 | TX | MEDICAID | 45-2578435-002 | 01 | TX | TRICARE | OTHER | 83Y684 | 01 | TX | BCBS OF TEXAS | OTHER | 5623482 | 01 | TX | AETNA | OTHER | P01572864 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 752616977022 | 01 | TX | HUMAN SOUTH MILITARY TRICARE | OTHER | 8FM313 | 01 | TX | BCBS | OTHER | 129809302 | 05 | TX | MEDICAID |