Provider Demographics
NPI:1407273428
Name:EAST TEXAS PHYSICIAN ASSISTANT SERVICES
Entity Type:Organization
Organization Name:EAST TEXAS PHYSICIAN ASSISTANT SERVICES
Other - Org Name:ETPAS
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:903-504-5353
Mailing Address - Street 1:5380 OLD BULLARD RD STE 600-125
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3607
Mailing Address - Country:US
Mailing Address - Phone:903-504-5353
Mailing Address - Fax:
Practice Address - Street 1:5380 OLD BULLARD RD STE 600-125
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3607
Practice Address - Country:US
Practice Address - Phone:903-504-5353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04135363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty