Healthcare Provider Details

I. General information

NPI: 1558775171
Provider Name (Legal Business Name): JORDAN PAYNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 ROSALIND REDFERN GROVER PKWY
MIDLAND TX
79701-5846
US

IV. Provider business mailing address

2215 NASHVILLE AVENUE
LUBBOCK TX
79410
US

V. Phone/Fax

Practice location:
  • Phone: 432-221-1111
  • Fax:
Mailing address:
  • Phone: 806-725-4800
  • Fax: 806-723-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR2440
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: