Provider Demographics
NPI:1356396808
Name:REDWINE, JANA LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:LEIGH
Last Name:REDWINE
Suffix:
Gender:F
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 1:301 UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3111
Mailing Address - Country:US
Mailing Address - Phone:806-797-4985
Mailing Address - Fax:806-744-7545
Practice Address - Street 1:301 UTICA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-3111
Practice Address - Country:US
Practice Address - Phone:806-797-4985
Practice Address - Fax:806-744-7545
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00277809OtherMEDICARE RAILROAD
TX8N7639OtherBLUE CROSS/BLUE SHIELD TX
TX8G0786Medicare ID - Type UnspecifiedMEDICARE #
TXQ28585Medicare UPIN