Provider Demographics
NPI:1124059589
Name:JAMESON, RICHARD A (PA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:JAMESON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:1302 N PACIFIC ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-1022
Practice Address - Country:US
Practice Address - Phone:903-569-5383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00460363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181502903Medicaid
TX858N25OtherBCBS
TX75-2616977-021OtherTRICARE
S61974Medicare UPIN
TX858N25OtherBCBS
TX181502903Medicaid
TX8A4991Medicare PIN
TX81N903Medicare PIN