Provider Demographics
NPI:1417450537
Name:AYASS LUNG CLINIC, PLLC
Entity Type:Organization
Organization Name:AYASS LUNG CLINIC, PLLC
Other - Org Name:AYASS LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JACOBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-655-7969
Mailing Address - Street 1:223 S ABE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6305
Mailing Address - Country:US
Mailing Address - Phone:325-655-7969
Mailing Address - Fax:325-655-7976
Practice Address - Street 1:8501 WADE BLVD STE 750
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-6437
Practice Address - Country:US
Practice Address - Phone:972-668-6005
Practice Address - Fax:972-668-6720
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AYASS LUNG CLINIC, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL5981OtherBC/BS