Provider Demographics
NPI:1790073435
Name:NASH, RONNIE DALE (PA)
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:DALE
Last Name:NASH
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:20208 STATE HIGHWAY 155 S
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:TX
Practice Address - Zip Code:75762-5600
Practice Address - Country:US
Practice Address - Phone:903-825-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07329363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-028OtherTRICARE
TX851N93OtherBCBS
TX75-2616977-001OtherTRICARE
TX75-2616977-002OtherTRICARE
TX752616977001OtherTRICARE
TX752616977002OtherTRICARE
TX283652001Medicaid
TX75-2616977-041OtherTRICARE
TX75-2616977-001OtherTRICARE
TX283652001Medicaid