Provider Demographics
NPI: | 1225883564 |
---|---|
Name: | PERMIAN ARTHRITIS AND RHEUMATOLOGY CENTER, PLLC |
Entity Type: | Organization |
Organization Name: | PERMIAN ARTHRITIS AND RHEUMATOLOGY CENTER, PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CREDENTIALING |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CANDACE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | WYNNE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 432-349-9730 |
Mailing Address - Street 1: | PO BOX 14955 |
Mailing Address - Street 2: | |
Mailing Address - City: | ODESSA |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 79768-4955 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 432-326-1939 |
Mailing Address - Fax: | 432-224-1091 |
Practice Address - Street 1: | 8050 E HIGHWAY 191 STE 203 |
Practice Address - Street 2: | |
Practice Address - City: | ODESSA |
Practice Address - State: | TX |
Practice Address - Zip Code: | 79765-8615 |
Practice Address - Country: | US |
Practice Address - Phone: | 432-326-1939 |
Practice Address - Fax: | 432-224-1091 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2024-04-19 |
Last Update Date: | 2024-04-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Single Specialty |