=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356396808
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANA LEIGH REDWINE PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 02/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 UTICA AVE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79416-3111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-797-4985
-----------------------------------------------------
Fax | 806-744-7545
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 UTICA AVE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79416-3111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-797-4985
-----------------------------------------------------
Fax | 806-744-7545
-----------------------------------------------------
=====================================================
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 | PA04272
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------