Provider Demographics
NPI:1629064977
Name:HEHMEYER, JACK N (PA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:N
Last Name:HEHMEYER
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: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:903-735-5355
Mailing Address - Fax:903-735-5399
Practice Address - Street 1:1205 E 35TH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2746
Practice Address - Country:US
Practice Address - Phone:903-735-5355
Practice Address - Fax:903-735-5399
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03299363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970025486OtherRAILROAD MEDICARE
ARPA-193OtherLICENSE
TX8N4180OtherBLUE CROSS
P50526Medicare UPIN
AR55158P067Medicare PIN
970025486OtherRAILROAD MEDICARE