Provider Demographics
NPI:1538167853
Name:WEST TEXAS A&M UNIVERSITY
Entity type:Organization
Organization Name:WEST TEXAS A&M UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:E
Authorized Official - Last Name:BUNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-355-5721
Mailing Address - Street 1:4400 S WASHINGTON ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79110-2052
Mailing Address - Country:US
Mailing Address - Phone:806-355-5721
Mailing Address - Fax:806-355-5775
Practice Address - Street 1:4400 S WASHINGTON ST
Practice Address - Street 2:SUITE 107
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79110-2052
Practice Address - Country:US
Practice Address - Phone:806-355-5721
Practice Address - Fax:806-355-5775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID#
TX00781VMedicare ID - Type Unspecified