Provider Demographics
NPI:1578544631
Name:DEVANE, JONATHAN R (PA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:DEVANE
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 1:1451 E HICKORY HILL RD
Mailing Address - Street 2:
Mailing Address - City:ARGYLE
Mailing Address - State:TX
Mailing Address - Zip Code:76226-2919
Mailing Address - Country:US
Mailing Address - Phone:940-464-4183
Mailing Address - Fax:817-355-4511
Practice Address - Street 1:1615 HOSPITAL PKWY
Practice Address - Street 2:STE. 210
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-5934
Practice Address - Country:US
Practice Address - Phone:817-540-3121
Practice Address - Fax:817-355-4511
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D8078Medicare ID - Type Unspecified
TXQ49630Medicare UPIN