Provider Demographics
NPI:1649309410
Name:REDWING, JONATHAN R (PA-C)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:REDWING
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 1:3414 GOLDEN RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8336
Mailing Address - Country:US
Mailing Address - Phone:903-939-7500
Mailing Address - Fax:903-939-7728
Practice Address - Street 1:3414 GOLDEN RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8336
Practice Address - Country:US
Practice Address - Phone:903-939-7500
Practice Address - Fax:903-939-7728
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2022-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA20070012363AS0400X
TXPA07915363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10034669OtherCIGNA/LOVELACE
NMP00465646OtherRAILROAD MCEDICARE
NM80203361Medicaid
NM00NM00RL61OtherBCBS
NM10034669OtherCIGNA/LOVELACE
NMP00465646OtherRAILROAD MCEDICARE