Provider Demographics
NPI:1629459623
Name:ASFAR, JOHN RUSTON (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSTON
Last Name:ASFAR
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 1:3025 N TARRANT PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-8629
Mailing Address - Country:US
Mailing Address - Phone:817-697-3900
Mailing Address - Fax:
Practice Address - Street 1:3025 N TARRANT PKWY STE 220
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-8629
Practice Address - Country:US
Practice Address - Phone:817-885-7827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8392NUOtherBCBS
TX355584901Medicaid
TX355584901Medicaid