=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275819328
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESUS ALFREDO TORRES PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2011
-----------------------------------------------------
Last Update Date | 05/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4060 MEDICAL PARK DR
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79765-2233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-582-2882
-----------------------------------------------------
Fax | 432-582-2884
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4060 MEDICAL PARK DR
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79765-2233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-582-2882
-----------------------------------------------------
Fax | 432-582-2884
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | PA07496
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------