=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437121274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFERY ALLEN SWANSON D.O., F.A.A.F.P.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2006
-----------------------------------------------------
Last Update Date | 01/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1417 9TH ST
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76301-4302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-222-5184
-----------------------------------------------------
Fax | 940-514-9089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4412 MONTEGO DR
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76308-4015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-257-8663
-----------------------------------------------------
Fax | 940-515-9089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | P1416
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------