Provider Demographics
NPI:1497494777
Name:EAST LAKE MEDICAL, PLLC
Entity Type:Organization
Organization Name:EAST LAKE MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DECANTER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:903-650-8619
Mailing Address - Street 1:11980 STATE HIGHWAY 64 E STE G
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-2541
Mailing Address - Country:US
Mailing Address - Phone:903-650-8619
Mailing Address - Fax:903-650-8576
Practice Address - Street 1:11980 STATE HIGHWAY 64 E STE G
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-2541
Practice Address - Country:US
Practice Address - Phone:903-650-8619
Practice Address - Fax:903-650-8576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty