Provider Demographics
NPI:1275000465
Name:ADVANCED PODIATRY ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:ADVANCED PODIATRY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ASIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:817-596-5077
Mailing Address - Street 1:1412 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5531
Mailing Address - Country:US
Mailing Address - Phone:817-596-5077
Mailing Address - Fax:817-598-0673
Practice Address - Street 1:1412 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5531
Practice Address - Country:US
Practice Address - Phone:817-596-5077
Practice Address - Fax:817-598-0673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-25
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty