Provider Demographics
NPI:1801468210
Name:VITAL PHYSICIAN SERVICES PLLC
Entity type:Organization
Organization Name:VITAL PHYSICIAN SERVICES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:HANNAH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:737-222-5553
Mailing Address - Street 1:3720 GATTIS SCHOOL RD STE 800
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-4660
Mailing Address - Country:US
Mailing Address - Phone:737-222-5553
Mailing Address - Fax:833-907-2248
Practice Address - Street 1:3720 GATTIS SCHOOL RD STE 800
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-4660
Practice Address - Country:US
Practice Address - Phone:808-646-1691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-14
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty