Provider Demographics
NPI:1649721366
Name:TIJERINO, MAX T (PA-C)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:T
Last Name:TIJERINO
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: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:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:703 S FLEISHEL AVE
Practice Address - Street 2:STE 5000
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2015
Practice Address - Country:US
Practice Address - Phone:903-525-2992
Practice Address - Fax:903-525-2685
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL390200000X
TXPA10936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-039OtherTRICARE
TX75-2616977-123OtherTRICARE
TX88117MAOtherBCBS
TX365425301Medicaid
TXP01762498OtherRAIL ROAD MEDICARE