Provider Demographics
NPI:1134417298
Name:FLORES, JONATHAN (PA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:FLORES
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 1:5015 FORT AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5828
Mailing Address - Country:US
Mailing Address - Phone:817-431-0606
Mailing Address - Fax:
Practice Address - Street 1:7630 N BEACH ST STE 140
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-3016
Practice Address - Country:US
Practice Address - Phone:817-281-2977
Practice Address - Fax:817-788-2530
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07374363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX316725601Medicaid
TXTXB134537Medicare PIN
TXTXB134541Medicare PIN
TX316725601Medicaid