Provider Demographics
NPI:1689244675
Name:NINAN, JAISON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAISON
Middle Name:
Last Name:NINAN
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 1:800 MEDICAL CENTER DR
Mailing Address - Street 2:STE C
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3844
Mailing Address - Country:US
Mailing Address - Phone:940-626-2110
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR STE C
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3844
Practice Address - Country:US
Practice Address - Phone:940-626-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant