MEDICARE: MR. JORGE LEDEZMA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA05266	TX

General Provider Information

NPI Number	:	1124238126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JORGE LEDEZMA PA-C

Provider Business Mailing Address
First Line	:	9550 FOREST LN STE 606
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-6176
Country	:	US
Telephone Number	:	469-804-7929
Fax Number	:

Provider Business Practice Location Address
First Line	:	9550 FOREST LN
Second Line	:	SUITE 606
City	:	DALLAS
State	:	TX
Zip	:	75243-5905
Country	:	US
Telephone Number	:	469-804-7929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	10/24/2013

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