Provider Demographics
NPI:1477535052
Name:SUMRALL, JENEVA L (PA)
Entity Type:Individual
Prefix:
First Name:JENEVA
Middle Name:L
Last Name:SUMRALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 AVE G
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-5866
Mailing Address - Country:US
Mailing Address - Phone:830-693-8234
Mailing Address - Fax:830-693-9090
Practice Address - Street 1:676 FM 517 RD W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539-3904
Practice Address - Country:US
Practice Address - Phone:713-482-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54327363A00000X
TXPA01264363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10013474OtherAMERIGROUP
TXTXB127387Medicare PIN
TX8398K5Medicare PIN
TX10013474OtherAMERIGROUP