Provider Demographics
NPI:1770761769
Name:PHYSICIAN NETWORK ASSOCIATION
Entity type:Organization
Organization Name:PHYSICIAN NETWORK ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF P.N.A
Authorized Official - Prefix:MR
Authorized Official - First Name:TREY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARTHING
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:1806-799-1326
Mailing Address - Street 1:4036 DUMONT DR
Mailing Address - Street 2:SAME AS ABOVE
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-7132
Mailing Address - Country:US
Mailing Address - Phone:432-368-2058
Mailing Address - Fax:
Practice Address - Street 1:4036 DUMONT DR
Practice Address - Street 2:SAME AS ABOVE
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-7132
Practice Address - Country:US
Practice Address - Phone:432-368-2058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAME AS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-01
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPAO1083305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service