Provider Demographics
NPI:1568132629
Name:MCINNIS, JOHN TYLER (NP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TYLER
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 811
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75504-0811
Mailing Address - Country:US
Mailing Address - Phone:903-614-5355
Mailing Address - Fax:903-614-5399
Practice Address - Street 1:600 W 52ND ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2980
Practice Address - Country:US
Practice Address - Phone:903-792-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAP214920363LG0600X
TXAP1023722363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology