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General NPI Number Information
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NPI Number | 1972680130
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Entity Type | Organization
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Legal Business Name | NORTHEAST TEXAS NEUROLOGY ASSOCIATES, P.A.
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 08/16/2022
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Provider Practice Location Address
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Address Line | 505 S FLEISHEL AVE
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City | TYLER
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State | TX
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Zip | 75702-8413
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Country | US
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Telephone | 903-526-7055
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Fax | 903-593-4303
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Provider Business Mailing Address
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Address Line | 505 S FLEISHEL AVE STE 800
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City | TYLER
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State | TX
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Zip | 75702-8413
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Country | US
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Telephone | 903-526-7055
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Fax | 903-593-4303
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GINA M. JETTER
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Credential | MD
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Telephone | 903-526-7055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | E6235
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License Number State | TX
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