Provider Demographics
NPI:1487768172
Name:AYASS LUNG CLINIC, PLLC
Entity type:Organization
Organization Name:AYASS LUNG CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD-AMMAR
Authorized Official - Middle Name:F
Authorized Official - Last Name:AYASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-655-7969
Mailing Address - Street 1:223 S ABE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6305
Mailing Address - Country:US
Mailing Address - Phone:325-655-7969
Mailing Address - Fax:325-655-7976
Practice Address - Street 1:3021 GREEN MEADOW DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6975
Practice Address - Country:US
Practice Address - Phone:325-223-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2116207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168067001Medicaid
TX0027LWOtherBCBS OF TX GROUP#
TX168067001Medicaid
TX00164XMedicare ID - Type Unspecified