Provider Demographics
NPI:1497050306
Name:MEDLEY, LINUS SCOTT (FNP)
Entity Type:Individual
Prefix:MR
First Name:LINUS
Middle Name:SCOTT
Last Name:MEDLEY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 TECHNOLOGY CTR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2697
Mailing Address - Country:US
Mailing Address - Phone:903-247-0484
Mailing Address - Fax:903-247-0485
Practice Address - Street 1:1711 S HENDERSON BLVD STE 300
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3563
Practice Address - Country:US
Practice Address - Phone:903-988-0605
Practice Address - Fax:903-988-9804
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR790626363LF0000X
TXAP142679363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX412015601Medicaid
TXAP142679OtherSTATE LICENSE