MEDICARE: JANUARY BANAAG JONES 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	PA05962	TX

General Provider Information

NPI Number	:	1437309309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANUARY BANAAG JONES PA-C

Provider Business Mailing Address
First Line	:	1645 N TOWN EAST BLVD
Second Line	:	SUITE 174
City	:	MESQUITE
State	:	TX
Zip	:	75150-4158
Country	:	US
Telephone Number	:	972-270-5549
Fax Number	:	972-270-5558

Provider Business Practice Location Address
First Line	:	1645 N TOWN EAST BLVD
Second Line	:	SUITE 174
City	:	MESQUITE
State	:	TX
Zip	:	75150-4158
Country	:	US
Telephone Number	:	972-270-5549
Fax Number	:	972-270-5558

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

Provider Enumeration Date	:	09/26/2008
Last Update Date	:	12/28/2008

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