Provider Demographics
NPI:1598119935
Name:VINTINNER, JACOB M (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:M
Last Name:VINTINNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 E PRESIDENT GEORGE BUSH HWY STE 404
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4278
Mailing Address - Country:US
Mailing Address - Phone:214-943-2200
Mailing Address - Fax:214-943-2201
Practice Address - Street 1:2821 E PRESIDENT GEORGE BUSH HWY STE 404
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-4278
Practice Address - Country:US
Practice Address - Phone:214-943-2200
Practice Address - Fax:214-943-2201
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10479363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant