Provider Demographics
NPI:1518131945
Name:LANDRETH, JAMIE SHARI (PA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:SHARI
Last Name:LANDRETH
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 1:2900 SAINT MICHAEL DR STE 401
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5211
Mailing Address - Country:US
Mailing Address - Phone:903-614-5393
Mailing Address - Fax:
Practice Address - Street 1:2604 SAINT MICHAEL DR STE 425
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2378
Practice Address - Country:US
Practice Address - Phone:903-614-5600
Practice Address - Fax:903-614-5630
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06337363A00000X
ARPA-336363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPA-336OtherLICENSE #
TXP02599453OtherRR MCR
TX1F4890OtherMEDICARE
OK200263770AMedicaid
TXPA06337OtherSTATE LICENSE