Provider Demographics
NPI:1902896863
Name:MCKINLEY, JAMES WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WAYNE
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 OLD BULLARD RD,
Mailing Address - Street 2:PMB 56
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4340
Mailing Address - Country:US
Mailing Address - Phone:903-312-4004
Mailing Address - Fax:888-242-8720
Practice Address - Street 1:1814 ROSELAND BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4234
Practice Address - Country:US
Practice Address - Phone:903-526-8754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4539207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123027808Medicaid
TX123027808Medicaid
TXE45985Medicare UPIN