Provider Demographics
NPI:1568474419
Name:SANDERS, JIMMY D (PA)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:D
Last Name:SANDERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 JOE RAMSEY BLVD E
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-7852
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4101 WESLEY ST STE E
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5635
Practice Address - Country:US
Practice Address - Phone:903-408-5860
Practice Address - Fax:903-408-5869
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA00444OtherLICENSE