Jack D Runyan, PA, PHD
Individual provider Active NPI Medical Physician Assistant · Fairfield, TX
NPI 1245476282 · NPPES record last updated Aug 7, 2018
Key facts
- NPI
- 1245476282
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Medical Physician Assistant 363AM0700X
- License
- PA 01154 (TX)
- Practice address
- 734 W Commerce St
Fairfield, TX 75840 - Phone
- (956) 572-4000
- NPI assigned
- Dec 22, 2008
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 4
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20050131000249 | TX | Practitioner - Physician Assistant | 4688624331 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant, Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA 01154 | TX | MD | Medical Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Pankaj V. Patel, M.D.,P.a. | Past | Accepting new patients | |
| P Douglas Cochran MD PA | Past | Accepting new patients |
Interoperability endpoints
- https://api.platform.athenahealth.com/14748/brand/1/csg/1/fhir/r4
- fmcjrunya@yourcarecommunity.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | PA 01154 | TX | Yes |
Addresses
Primary practice location
734 W Commerce St
Fairfield, TX 75840
Mailing address
734 W Commerce St
Fairfield, TX 75840-1428
Phone (903) 389-2181
Other providers in Fairfield, TX
- Matthew Noble
- Vance J Oglesbee
- Ignacio William Perez
- Katie Randall
- Cheryl F Roberts
- Lana Satterwhite
- Brenda Scott
- Merlin Leroy Shriner
- Brian J. Shultz
- Emily Sikes
All providers in Fairfield, TX · Medical Physician Assistant in Texas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 7, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.