Provider Demographics
NPI:1548448186
Name:LEFTWICH, TENNILLE L (PA-C)
Entity type:Individual
Prefix:
First Name:TENNILLE
Middle Name:L
Last Name:LEFTWICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-7738
Mailing Address - Country:US
Mailing Address - Phone:469-562-1265
Mailing Address - Fax:469-484-0648
Practice Address - Street 1:3901 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7738
Practice Address - Country:US
Practice Address - Phone:469-562-1265
Practice Address - Fax:469-484-0648
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05559207T00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174014100OtherFIRST CARE
TXP00629320OtherMEDICARE RAIL ROAD
TX193513201Medicaid
TX8Y3719OtherBCBS
TX193513201Medicaid