Provider Demographics
NPI:1285881755
Name:POMALES, JENNIFER LYNN (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:POMALES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 RIVERHEAD DR
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-8735
Mailing Address - Country:US
Mailing Address - Phone:214-641-5787
Mailing Address - Fax:
Practice Address - Street 1:704 RIVERHEAD DR
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-8735
Practice Address - Country:US
Practice Address - Phone:214-641-5787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197786001Medicaid
TX197786003Medicaid
TX197786002Medicaid
TX197786003Medicaid
TX197786002Medicaid
TX8L2371Medicare PIN
TX8L1970Medicare PIN
TX8L2373Medicare PIN