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["Providers Full Name","Providers NPI","Tax ID#","State","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indv ID#","Grp ID#","Note Date","Notes","Symplr Rep","Enroll Type","Practice Address","Practice Address 2","Practice City","Practice Zip Code"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-10-17","","","2023-10-27","Ste. 102 and 103 effective 10/17/2023 has been approved. MD"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2023-10-17","","","2023-10-27","Ste. 102 and 103 effective 10/17/2023 has been approved. MD"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Stopped","2023-10-17","","","2023-11-06","Ste. 240, 205, and 107 have been confirmed as non current service addresses. Provider should only be linked to Ste. 103. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Stopped","2023-10-17","","","2023-11-06","Ste. 240, 205, and 107 have been confirmed as non current service addresses. Provider should only be linked to Ste. 103. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2018-08-29","","","2023-11-22","11/22/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/29/2018.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-07-19","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19","","","2023-11-07","11/7/2023 Per email received from Galaxy October delegated roster has been processed and provider is PAR and linked to group/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-07-19","6670877","","2023-11-08","Received confirmation of update. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-07-19","5117734","","2023-11-19","11.29.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 07/19/2023. Next recredentialing date is on 07/19/2026. PIN: 5117734. Servicing location is on file. Payer# 60054. Call ref# 6172179371. - Willie Ravas"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-19","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-10-17","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-11-03","11/3/2023 Rcvd confirmation email from UHC/Wellmed that provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-10-01","679507","0008AH","2024-02-07","Location was added to group record eff 10/1/2023. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-07-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Enrollment Complete","","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-07-19","1046218","","2023-12-06","12/6/2023 S/W Kim of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, Provider is in network with First Health and linked to the group and TIN# effective 7/19/2023.  PIN: 1046218. Servicing location is on file. No payer# available. DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-03-06","Application in PE Review status. Jen Videan"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2018-07-10","002539407","","2023-11-03","11/3/2023 Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 7/10/2018.  MPIN # 002539407.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-10-13",""]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","11483093","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2013-12-27","1023520830","463131679","2020-08-18","Confirmed provider is participating under delegated agreement for PPO and H&W Networks (list of networks attached). Kim Frazier"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","","","2020-09-11",""]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-20","","","2021-03-24","3/24/2021 Confirmed provider is already certified as a non-network provider. KFrazier"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing the follow up complete note - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2018-05-02","1023520830","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-11-10","","","2021-09-14","9/14/2021 Per Tricare portal, provider is participating with TaxID as of 11/10/2020. Cbankston"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2020-07-21","07/21/20220 - Rec'd email confirmation that this name change has been completed. Signed into PECOS to verify - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1023520830","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-06-15","1023520830","","2020-10-05","Enrolled thru PHCS"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-06-15","1023520830","52669: West Texas Physicians Alliance Group Cntrct","2020-03-11","03/11/2020 - Rec'd email response from the payer stating provider is effective with different networks/effective dates as follows:\n\"Network:  MPI \nNetwork Participation effective: 10/01/2019 Group contract through: West Texas Physicians Alliance\n\nNetwork:  PHCS\nNetwork Participation effective: 06/15/2018 Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech St.\nNetwork Participation effective: 11/27/2019 Group contract through: West Texas Physicians Alliance\"\n\nAll are linked to group TIN - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-01-24","14145595","","2024-01-23","01/23/2024 CAQH Reattested wthompson"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2018-03-19","382485601","079837301","2023-05-10","5/10/2023 Rcvd TX Medicaid revalidation approval letter.  Provider is PAR and linked to group.  TPI # 1023520830 - effective 3/19/2018.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-07-11","1023520830","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-05-30","1023520830","","2020-06-05","06/05/2020 - Rec'd email from payer stating this provider is EFF - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-06-29","1023520830","","2020-07-09","07/09/2020 - Rec'd welcome letter from Multiplan stating provider is covered for all governmental payers - Amerigroup is covered (STAR, Star Plus, Star Kids) - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-05-19","12623755","","2021-08-05","7/26/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 5/19/2020 with assigned provider number 12623755. KFrazier"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-09-01","1023520830","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this providers name update from Brown to Reeves has been completed EFF 9-1-2020 - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2018-05-01","3128029","","2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 5/1/2018 PID # 3128029\ntisha rader"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","IMS is complete"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1104237015","","2020-06-05","06/05/2020 -Rec'd email from the payer stating provider is EFF - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2017-09-01","3094146","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2017 PID # 3094146\ntisha rader"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","2018-07-01","1790767119","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2018-07-11","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1104237015","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-16","1104237015","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with HMO/PPO only products with this TIN/Service Location- Stacey Hudak\n\n**Verified that this provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nPPO Limited Benefit Network"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2018-06-19","","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of  6/19/2018. – Elonah Grace B. Gelig"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-13","1104237015","","2020-08-27","08/27/2020 - Rec'd email back from the payer stating \"Thank you for contacting our Customer Service Department with Multiplan/PHCS. We received your request have confirmed that the following providers are participating with Multiplan and PHCS through Midland Pediatric Associates: - Coby Robins-Effective 08/13/2018\"  - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-07-11","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating effective 7/11/2018 with the correct practice location. Kimberly Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","14218808","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2018-07-18","1104237015","","2020-07-15","07/15/2020 - Rec'd email through Humana Secure Mailbox stating \"i have attached a small roster with providers still active under that tin but also not on your roster.\"  I confirmed that this provider does remain effective with our group - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete","2018-07-31","1104237015","752133441","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kim Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2017-09-17","1104237015","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2018-08-13","1104237015","","2020-10-05","Enrollment thru PHCS"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2018-10-11","1104237015","","2020-04-15","04/15/2020 - Rec'd follow up team statement saying \"S/W Francis of Cigna@ 8008824462, provider NPI is on file for the provider and participating effective 10/11/18 under the group and TIN with Direct contract. Physical location is on file. Call ref# FRANCIS04142020. \"  PROVIDER IS PART OF A DIRECT CONTRACT - Stacey Hudak"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Humana","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-20","","","2024-01-09","Received confirmation via self service portal. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","USA PPO","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email rcvd from Karen Avalos at Galaxy December roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","BCBSTX","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","TriCare Standard","Enrollment on Hold","Enrollment on Hold","","","","2024-03-13","Received TIN access, but the group is set up as a ambulance facility and providers are unable to be added. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 10/09/2023 and linked to 400 Rosalind Redfern, Suite 230. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-01","Pending Medicare approval. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Wellmed","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending Multiplan enrollment.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","IMS","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Galaxy Health","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-24","Pending Aetna approval. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Cigna","In Process","Application Submitted","","","","2024-03-04","Application submitted to PSScentral. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","2024-02-28","Re-Cred has been completed eff 1/2/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Omni PPO","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-11-06","","","2024-02-15","Per phone call, the provider is linked to TIN eff 11/6/2023. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Scott&White (First Care)","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Multiplan","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-11-01","","","2023-12-19","Rcvd TMHP Welcome letter. Provider effective 11/01/2023. Jen Videan"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","HealthSmart PPO","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Cigna Healthspring","In Process","Application Submitted","","","","2024-03-06","Letter of Interest submitted via email. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-04","Location is not Tricare Credentialed. Panel is closed. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Boon Chapman","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","In Process","Payor Follow Up","","","","2024-01-16","1/16/2024 Sent follow-up email to Jessica Bess at Multiplan to check status of December roster.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Application Submitted","","","","2023-12-15","12/15/2023 Delegated roster submitted.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Medicaid","Enrollment on Hold","Enrollment on Hold","","","","2024-03-04","Enrollment on hold until Medicare issue is resolved and enrolled. Jen Videan"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-06","00920011605","","2024-01-29","1/29/2024 Per UHC provider portal provider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00920011605.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","United Health Care","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","First Health Coventry","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-11-01","6C4889","","2023-11-28","Provider is already enrolled with this group and locations. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Caprock (CapStar)","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Triwest VA","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Superior","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  Sent follow-up email to LaNetrice Myart to check status of December roster submission.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Application Submitted","","","","2023-12-15","12/15/2023 Delegated roster submitted.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Amerigroup","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","PPHP","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-06","008925217","","2024-01-23","1/23/2024  Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 11/6/2023.  MPIN # 008925217.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Aetna","Provider Load","Provider Load","","","","2024-03-01","Provider is joining City of Midland Health effective 2/1/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-12-01","0446524","","2023-12-04","Received approval email effective 12/01/23. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-11-05","Panel is closed to new providers until further notice. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-11-03","11/3/2023 CAQH profile maintained by practice.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/6/2023. PA."]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-11-01","8096880","","2024-01-03","Received confirmation. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-11-06","","","2023-12-07","Provider is linked to the group eff 11/6/23. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-11-06","008167479","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 008167479.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Rcvd email confirmation from Jessica Bess at Multiplan that November roster has been processed and provider is PAR w/ group effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2023-11-06","","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 008167479.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","","","2023-09-06","Confirmed this provider was added. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-01","008092273","","2024-01-30","1/30/2024 Rcvd email confirmation from UHC that January delegated roster has been completed.  Provider is PAR and linked to group/location effective 2/1/2024.  MPIN # 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-18","Received confirmation of enrollment. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-13","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00274901","","2022-06-11","Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00274901 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-13","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-02-01","6819516","","2024-01-09","Received confirmation of enrollment. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-12-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2024-03-12","Emailed Texas Mutual (wwtxcontracts@texasmutual.com) for update on site visit. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-13","","","2022-09-27","9/27/2022 Per follow-up note -  Provider NPI# is on file and in network with USA MCO. Link to the group and TIN# effective 6/13/2022. Location is on file, Provider ID is 1334093. Next recredentialing date is 6/13/2025. DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-06-13","1334093","","2022-08-23","08/23/2022 - Per follow-up note - Per email response received from Corvel Healthcare Corp on 08/17/2022. Provider NPI# is on file active and par under the TIN and Group effective 06/13/2022. Physical location is on file. Provider ID 1334093.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-27",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","","","2023-09-06","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2022-06-13","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-10-02","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-19","6910036","","2023-09-19","09.19.2023 S/W Joe of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 06/19/2023. PIN: 6910036. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163696629. - Willie Ravas"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2022-09-16","9/16/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2024-02-13","Provider effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","6910036","","2022-07-28","7/28/2022 Per follow-up note:  07.14.22. S/W Rachel of Aetna @ 1-800-353-1232. Provider NPI# is on file for the provider and is participating effective 07/01/22 under the group and TIN#. PIN 6910036. Physical location is on file. Ref# 6100299498 - Ria Dee Bieren  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/13/2022.  PID # 3567571.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-05-17","","","2024-03-05"," Per spneast@sedgwickcms.com address has been added to provider's profile effective 05/17/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Per Healthsmart provider portal provider is still not loaded under group TIN.  Provider still not updated will allow more time, check back in 2 weeks.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-12-19",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","00008092273024","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-07","Application to add this location to Medicare is still pending with Medicare. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2024-02-13","Please see status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-07","The group application to add this location was submitted and is still processing. Once the this location has been added at the group level, the provider will automatically be enrolled at this location as well. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-12-19",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-01","3567571","","2023-09-20","09.20.2023 S/W Ashnti of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, provider is in network with First Health for the state of TX and linked to the group and TIN# effective 06/01/2022. Next recredentialing date is on 06/01/2025. PIN: 3567571. Servicing location is on file. Payer# 73159. Call ref# 760029. - Willie Ravas"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2023-01-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2023-05-17","received approval letter from Careworks effective 5/17/2023. MS."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-06-19","6819516","","2023-09-19","09.19.2023 S/W Sofie of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 06/19/2023. Provider ID 6819516. Service location is on file. Call ref#:SofieS09192023."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-07-22",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2022-05-27","5/27/2022 Rcvd Medicare approval letter.  PTAN # 2E0739 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2023-08-02","Rcvd approval letter from TMHP. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2023-04-14","","","2023-07-26","7/26/2023 Per email received from IMS/OMNI February delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-04-14","","","2023-07-12","Received confirmation email from rep. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2023-05-19","","","2023-07-18","Michelle Killough confirmed provider is effective 5/19/2023. MS See Alliance for enrollment note updates."]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","In Process","Payor Follow Up","","","","2024-03-12","Per maria.lightner@careworks.com send roster with CAQHs, W9 and COIs. Requested information emailed to Maria. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2023-04-14","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2023-04-14","","","2023-07-20","7/20/2023 Per email received from Galaxy April  delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-04-14","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2023-04-14","","","2023-05-31","05.31.2023 S/W Anthony of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 04/14/2023. Provider ID 9850849, Payer ID 60054 and Recredentialing date is not required due to provider is delegated. Service location is on file. Call ref#:6149186847. - Danico Gabriel Melendres"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Enrollment on Hold","Pending Contracting","","","","2024-03-05","Emailed providerrelations@primehealthservices.com for status of contract. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next roster submission. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-26","Not listed in Coventry portal, will need added to next roster submission. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2023-05-01","","","2023-12-28","12/28/2023 Per UHC web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-08-21","Received confirmation. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2T0202","","2023-05-10","5/10/2023 Rcvd Medicare approval letter.  PTAN # 2T0202 - effective 5/1/2023.   DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2023-07-01","","","2023-09-15","Received confirmation email with effective date. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-10-19","Received enrollment confirmation. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2023-05-19","","","2023-05-22","Michelle Killough confirmed provider is effective 5/19/2023. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2023-04-14","","","2023-09-19","9/19/2023 - Received email that delegation roster has been completed.  Provider is PAR and linked to group TIN/location effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2023-04-14","","","2023-06-21","Rcvd effective date of 4/14/2023 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2023-05-01","003614004","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 5/1/2023.  MPIN# 003614004.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next roster submission. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2023-04-25","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2023-08-01","","","2023-08-08","Rcvd approval letter. Effective 08/01/2023. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2023-04-14","","","2023-07-26","7/26/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-04-14","","","2023-10-13","10/13/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-18",""]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-04-14","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from April has been completed and provider is PAR effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2023-04-14","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed in Coventry portal. Please add to next roster submission. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed in Coventry portal. Please add to next roster submission. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2018-07-31","1740542034","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-09-20","1740542034","","2020-08-20","08/20/2020 - Rec'd emailed spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1740542034","","2020-06-10","06/10/2020 - Rec'd email from the payer stating provider is EFF - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2018-07-31","1740542034","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice)  stating this provider is EFF at this service location with Amerigroup - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2018-09-01","1740542034","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1740542034","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2024-01-29","","","2024-01-29","01/29/2024 CAQH Reattested wthompson"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-16","1740542034","","2020-09-08","09/08/2020 - Found response from the payer stating \"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Multiple providers listed below:\n\nNetwork: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\nRyan S Rowland, MD NPI: 1740542034 – \n5026 – West Texas Physicians Alliance –  Beech St Eff Date 07/11/2018\n23655 – West Texas Physicians Alliance –  MPI Eff Date 08/16/2018\n52669 – West Texas Physicians Alliance – PHCS Eff Date 08/16/2018\" - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note from 8/28/2020 - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-08-01","3165726","","2020-03-20","03/20/2020 - Recd email from the payer stating this provider is effective under PID# 3165726  - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-26","06/26/2020 - EFF IF IMS IS EFF - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2018-08-01","1740542034","","2020-04-23","04/23/2020--S/W Kim of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 8/1/2018. Physical Location is on file. Provider ID #6404238. Call ref # 5234162545\ncopied note from spreadsheet-tisha rader"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-05-20","1346807278","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2020-08-01","1346807278","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2020-05-13","1346807278","","2020-09-08","09/08/2020 - Rec'd email response from the payer stating \" Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below:\n\nPamela F Doughty, PA NPI: 1346807278\n5026 – West Texas Physicians Alliance –Beech St Eff Date 05/06/2020\n23655 – West Texas Physicians Alliance – MPI Eff Date 05/13/2020\n52669 – West Texas Physicians Alliance – PHCS Eff Date 05/13/2020\"\n- Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2024-01-29","","","2024-01-29","01/29/2024 CAQH Reattested wthompson"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","In House Enrollment","2020-01-05","412587401","325373401","2020-08-13","8/13/2020 - rec'd effective letter from the clinic. HOwever, this is not a payer that they asked Symplr to maintain. Created a payer line to house effective info if needed by another payer for enrollment - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2021-01-26","1312287","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2020-12-10","12/10/2020 - Per First Health provider is active and linked to practice location effective 9/1/2020.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2020-05-06","13725946","","2020-07-21","07/21/2020 - rec'd email with a spreadsheet from the payer stating this provider/TIN/service location are all PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 4/15/2020.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","1346807278","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is now participating under group Tax ID effective 9/1/2020 and assigned PIN number 6962996. Kimberly Frazier"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-10-26","1649462987","475554737","2020-08-18","Confirmed provider is participating with PPO and H&W Networks (list of networks attached). Kimberly Frazier"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-01-02","","","2024-01-02","01/02/2024 CAQH Reattested WT"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1649462987","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-08-01","1649462987","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2018-10-01","2506877","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 2506877 - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2018-11-15","1649462987","","2020-02-03","02/03/2020 - Rec'd confirmation from the follow up team that this provider is \"in network-participating-DIRECT contracted\" EFF 11-15-2018. Unfortunately, no reval date was provided, but it was confirmed that this service location is linked to the provider. - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2018-08-01","387144401","364596201","2023-12-19","Revalidation approval letter rcvd. Effective 08/01/2018. Jen Videan"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-08-01","685085","519061","2020-04-22","04/22/2020 - found EFF info through group PECOS enrollment - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-26","1649462987","","2020-08-19","8/19/2020 - Rec'd a new spreadsheet from Baylor Scott & White after they merged databases with First Care. Updated the effective date and this provider is showing up affilaited with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-08-01","P02179384","DW7662","2020-04-22","04/22/2020 - Confirmed provider EFF info through payer portal - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2018-12-01","1649462987","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 12-1-2018  **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-11-30","1649462987","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-10-22","","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1407149883","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-02-12","1407149883","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-01-23","","","2024-01-23","01/23/2024 CAQH Reattested wthompson"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-11-30","1407149883","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2018-10-01","3060094","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 3060094 - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-08-01","1407149883","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 8-1-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-08-27","1407149883","","2020-09-23","09/23/2020 - Reviewed follow up complete note and moved to completed status - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-09-01","P02262526","","2020-03-25","3/25/2020--Per online check, provider is now PAR effective 09/01/2018 with provider number P02262526. Attached welcome letter to payor line\n--tisha rader"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-06-05","060/5/2020 - Rec'd email from the payer stating this provider is EFF - Stacey HUdak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2018-12-01","1407149883","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 12-1-2018 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2018-09-01","377470502","364596201","2023-08-22","Revalidation approval ltr rcvd via TMHP website. Effective 09/01/2018. Jen Videan"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-25",""]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-09-01","691156","519061","2020-02-19","02/19/2020 - Rec'd PECOS login .Signed in to find that this provider is successfully enrolled with Medicare/MIMA as of 9-1-2018. - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-10-26","1407149883","475554737","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-08-01","1407149883","","2020-07-30","7/30/2020 - moved to completed status after reviewing followup complete note - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2018-11-15","1407149883","","2020-02-03","02/03/2020 - Rec'd confirmation from the follow up team that this provider is \"in network-participating-DIRECT contracted\" EFF 11-15-2018. Unfortunately, no reval date was provided, but it was confirmed that this service location is linked to the provider. - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-08-27","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 8/27/2020.  DCannon"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","In Process","Application Submitted","","","","2024-03-12","Email sent to Medical Onboarding to enroll provider. MS"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-12","Location is not Tricare Credentialed, panel is closed. MS"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","In Process","Application Submitted","","","","2024-03-13","Application to link provider was submitted via portal. MS"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","2018-01-16","560990YSCJ","290001","2020-07-24","7/24/2020 - Confirmed this provider is linked to Quick Care Clinic Part B group PTAN 290001 - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Boon Chapman","Participating","Enrollment Complete","2020-07-17","","","2022-09-15","9/15/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Molina","Pending Other Enrollment","Payor Follow Up","","","","2023-10-16","10/16/2023 Sent a 2nd request follow-up email to MHTContractRequest@molinahealthcare.com.  Forward original email request submitted back in 2021 to follow-up on request.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-07-17","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2020-10-01","1740723725","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the PriMed roster - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2018-07-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 7/1/2018.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2020-09-01","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2018-04-30","1740723725","","2020-07-23","07/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-26","1312289","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2023-05-16","05.16.2023 S/W Jerome of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 09/01/2020. Provider ID 3385653, No Payer ID and No Recredentialing date. Service location is on file. call ref#:633322.-Danico Gabriel Melendres"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2020-07-17","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-02","1740723725","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer stating this provider has been added to the PRIMED DELEGATED AGREEMNT under this TIN/Service Location. The provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1740723725","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","1740723725","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2018-04-01","","","2020-09-24","Confirmed via self-service portal, provider is participating under group Tax ID and location. Kimberly Frazier"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Participating","Enrollment Complete","2018-01-16","378143702","324676101","2021-02-10","2/10/2021 Per email received from Stacy Salazar, she processed provider's application, which has been approved and assigned TPI 378143702 effective 1/16/2018. KFrazier"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-07-17","","","2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 7/17/2021.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1740723725","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2024-01-29","","","2024-01-29","01/29/2024 CAQH Reattested wthompson"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-01-12","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/12/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2021-12-08","12/8/2021 Per email from Mary Hanna @ Aetna provider is PAR and linked to group/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment status. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment status. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment status. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment status. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment status. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment status. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment status. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment status. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment status. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment status. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2023-11-28","Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2022-04-01","","","2022-04-07","4/7/2022 Received welcome letter from wwtxcontracts@texasmutual.com, provider is par and eff 4/1/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3208919","","2023-01-09","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 11/1/2022. Location is on file. Provider ID is 3208919. Next recredentialing date is every 3 years (11/1/2025). No information for the payer#. -Kim Monique Fabian. -Kim Monique Fabian"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-10-18","","","2023-10-23","Rcvd acceptance ltr from cynthia.clancy@sedgwick.com. Provider is effective 10/18/2023 at 210 W Longview Ave. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-09-29","9/29/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-09-29","9/29/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-09-29","9/29/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-09-29","9/29/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-03","Panel is closed, per the payor until further notice. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-03","Panel is closed, per the payor until further notice. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-03","Panel is closed, per the payor until further notice. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-03","Panel is closed, per the payor until further notice. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-03","Panel is closed, per the payor until further notice. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-03","Panel is closed, per the payor until further notice. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-03","Panel is closed, per the payor until further notice. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-03","Panel is closed, per the payor until further notice. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-03","Panel is closed, per the payor until further notice. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-03","Panel is closed, per the payor until further notice. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2023-09-29","9/29/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 9/1/221.  PID # 1U8148.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email from Aetna provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email from Aetna provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email from Aetna provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email from Aetna provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is linked to Briarwood and Eastridge locations eff 10/9/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-29",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-01-12","1277846","","2022-02-24","02/24/2022 Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and is participating under the group and TIN effective 01/12/2022. PIN# 1277846. Next recredentialing date is on 01/12/2025. Physical location is on file. No Payer#. Call ref#  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-03-22","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 03/22/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-03-22","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 03/22/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-03-22","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 03/22/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-03-22","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 03/22/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-03-22","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 03/22/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-03-22","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 03/22/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-03-22","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 03/22/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-03-22","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 03/22/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-03-22","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 03/22/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-03-22","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 03/22/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-09-26","9/26/2021 Processed in-house through BCBSTX. KFrazier"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-01-14","","","2024-02-13","Provider effective 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-10-02","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-01-14","","","2024-02-13","Please see status updates under Alliance WC payor line. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-10-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 10/1/2021.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI August delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-02","14399669","","2024-02-02","02/02/2024 CAQH Reattested updated and uploaded license wthompson"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-02","14399669","","2024-02-02","02/02/2024 CAQH Reattested updated and uploaded license wthompson"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-02","14399669","","2024-02-02","02/02/2024 CAQH Reattested updated and uploaded license wthompson"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-02","14399669","","2024-02-02","02/02/2024 CAQH Reattested updated and uploaded license wthompson"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-02","14399669","","2024-02-02","02/02/2024 CAQH Reattested updated and uploaded license wthompson"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-02","14399669","","2024-02-02","02/02/2024 CAQH Reattested updated and uploaded license wthompson"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-02","14399669","","2024-02-02","02/02/2024 CAQH Reattested updated and uploaded license wthompson"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-02","14399669","","2024-02-02","02/02/2024 CAQH Reattested updated and uploaded license wthompson"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-02","14399669","","2024-02-02","02/02/2024 CAQH Reattested updated and uploaded license wthompson"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-02","14399669","","2024-02-02","02/02/2024 CAQH Reattested updated and uploaded license wthompson"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-10-06","10.6.2023 S/W Mark of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 09/1/2021. Physical location is on file. No next recredentialing date available.   DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3208919","","2023-09-29","9/29/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 3208919.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3208919","","2023-09-29","9/29/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 3208919.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3208919","","2023-09-29","9/29/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 3208919.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3208919","","2023-09-29","9/29/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 3208919.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-18","Received confirmation of enrollment. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-09-01","","","2023-10-20","Received confirmation of completion. Provider ID 0607671 Effective 9/1/2023. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-09-10","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 9/10/2020.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-01-03","Group holds an Ancillary contract which will bill for the midlevel services under the group. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-09-01","","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from October has been completed and provider is PAR effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-28","Added Alliance WC payor line. Texas Municipal League is through Alliance WC. TML added so adding Alliance WC now. Per TML payor line provider is par 01/14/2022. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI August delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2021-09-01","","","2021-11-20","11/20/2021 Per email received from Galaxy October delegated roster has been processed and provider is PAR and linked to group/location effective 19/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2021-09-01","","","2021-09-26","9/26/2021 Group is contracted as an ancillary facility, so no enrollment is required. KFrazier"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Morgan Sims. Effective 12/05/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Morgan Sims. Effective 12/05/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Morgan Sims. Effective 12/05/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Morgan Sims. Effective 12/05/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Morgan Sims. Effective 12/05/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Morgan Sims. Effective 12/05/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-10-18","","","2024-03-05"," Per spneast@sedgwickcms.com address has been added to provider's profile effective 10/18/2023. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","","","2023-10-12","10/12/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 3208919.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 04/01/2022 Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 04/01/2022 Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 04/01/2022 Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 04/01/2022 Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 04/01/2022 Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 04/01/2022 Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-09-29","9/29/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-30","1/30/2024 Per UHC portal provider load in Wellmed is still pending.  Will check back in a few days.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-09-01","Q00157212","","2021-11-02","11/2/21 Effective 9/1/21, PTAN Q00157212. Please allow three business days for the activation of this new PTAN. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","007021658","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 1/1/2022.  MPIN # 007021658.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2021-10-01","10/1/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN # 1U8148 - effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-12-20",""]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-07","Application to add this location to Medicare is still pending with Medicare. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-01-14","","","2022-02-28","2/28/2022 Received email from michelle.killough@pswca.org, provider is par with location eff 1/14/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Per Healthsmart provider portal provider is still not loaded under group TIN.  Provider still not updated will allow more time, check back in 2 weeks.   DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2024-03-07","The group application to add this location was submitted and is still processing. Once the this location has been added at the group level, the provider will automatically be enrolled at this location as well. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-12-17","","","2022-01-04","1/4/2022 Per Tricare portal, provider is linked to locations as of 12/17/2021. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-01","007021658","","2024-01-30","1/30/2024 Rcvd email confirmation from UHC that January delegated roster has been completed.  Provider is PAR and linked to group/location effective 2/1/2024.  MPIN # 007021658.   DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2023-09-29","9/29/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2024-03-12","Emailed Texas Mutual (wwtxcontracts@texasmutual.com) for update on site visit. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-03-01","774291","320497","2021-09-10","9/10/2021 Received written revalidation approval for provider under provider PTAN 774291. KFrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2020-05-21","1588857874","","2020-09-23","09/23/2020 - moved to completed status after reviewing the follow up completed status - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/24 CAQH Reattested wthompson"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1588857874","","2020-06-25",""]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","380896603","331090601","2020-07-15","07/15/2020 - logged into TMHP and found that this provider is EFF - TPI 380896603 - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-05-21","1588857874","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 6-1-2019 under a DIRECT CONTRACT with this payer. This service location is on file and linked to the provider. -Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2019-05-31","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 5/31/2019.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2019-09-01","1588857874","","2020-02-10","02/10/2020 - Rec'd confirmation from payer that this provider is EFF at 5615 Deauville, Ste 220 through a DELEGATED PAYER (Permian Basin Healthcare Network) and linked to the following products: STAR, HEALTH FOSTER CARE, STAR, STAR PLUS, CHIP RSA,\nSTAR KIDS, CHIP, CHIP PERINATE, also EXCHANGE (exchange only since 1-1-2014; non par) All other products are PAR since 9-1-2019. - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2019-05-31","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 5/31/2019. Kfrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-02-20","02/20/2020 - Had the follow up team call CIgna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 4-4-2019 under a DIRECT CONTRACT at this service location."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2019-11-01","","","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 11/1/2019.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2650428","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 2650428 - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2019-04-19","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-03-01","P02232681","DU5783","2020-02-21","02/12/2020 - Found effective info through payer site stating provider is PAR with group PTAN:  DU5783 EFF 3-1-2019. - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1588857874","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","","","2020-09-04","Provider is participating under group Tax ID and correct location. Kimberly Frazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 3/6/2019.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2019-05-31","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 5/31/2019. Kfrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1588857874","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2019-05-21","1588857874","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2021-02-12","1588857874","","2023-09-20","9/20/2023 Per email from Amerigroup provider is PAR and linked to group TIN effective 2/12/2021.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-31","1588857874","","2020-08-19","8/19/2020 - Rec'd spreadsheet from the payer confirming this provider is linked to the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2019-04-19","1588857874","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1588857874","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1588857874","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019. – Archie Candiasan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-03-06","1164778767","","2020-02-20","02/20/2020 - Had the follow up team call CIgna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 3-6-2019 at this service location. They also said this provider IS DELEGATED; but could not say who the delegated company is. - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-02-18","779243","320497","2020-01-30","01/30/2020 - Found this provider is linked to Midland Texas Ortho (group PTAN 320497 and Employer ID# 1346681061) as of 2-18-2019. MAURENE.MCDANIEL@MIDLANDHEALTH.ORG  is the contact person - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2021-02-12","1164778767","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 2/12/2021.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2014-01-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 1/1/2014. Kfrazier"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2019-02-18","362149203","331090601","2024-02-21","Rcvd revalidation approval ltr. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","3039403","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 3039403 - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1164778767","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","","","2020-08-05","8/5/2020- Per email response received from  Texas Mutual on  8/4/2020, provider NPI# is on file for the provider and is participating effective 5/1/2019 under the group and TIN#. Physical location is on file. - Elonah Grace B. Gelig"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1164778767","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1164778767","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2019-06-06","1164778767","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2019-11-01","1164778767","463131679","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 11/1/2019.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-04-13","","","2020-10-02","10/2/2020 - Rec'd response from the payer stating \"•\tProviders marked as \" Delegated Contract With SHP” have an active delegated contract with another entity by the same NPI & TIN through Superior Health Plan. Please note that these providers will not be accepted as part of your Delegated Opt-in. \" \nWe cannot add this provider to the PriMed delegation, as they are already with another delegated group- Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2019-06-06","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 5/1/2020.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2020-05-21","1164778767","","2020-09-23","Provider is delegated under Physician Optimal INC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2019-05-31","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 5/31/2019.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2014-01-01","","","2020-07-27","7/27/2020- S/W  Jack of  Gallagher (thru Coventry) @ 800-243-2336 and she transferred the call to cred dept. S/W  Lynn  and  she confirmed group is par with Worker's Comp Network under the TAX ID eff 1/1/2014.  Provider is  par as a delegated  with Worker's Comp Network under the TAX ID eff 5/1/2019. Physical location is on file. Group ID# 2559513 and Individual ID# 3039403. Call ref#181324888. - Elonah Grace B. Gelig"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-02-18","P02405660","","2020-03-25","3/25/2020- Per online check, provider is now PAR effective 02/18/2019 with provider number P02405660. Attached welcome letter to payor line\n-tisha rader"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1164778767","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-25",""]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1639524861","","2020-07-17","7/17/2020 - received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-09-15","","","2023-08-18","8/18/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-16","1639524861","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 4-16-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-30","13859704","","2024-01-30","01/30/2024 CAQH Reattested wthompson"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2024-01-30","13859704","","2024-01-30","01/30/2024 CAQH Reattested wthompson"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-30","13859704","","2024-01-30","01/30/2024 CAQH Reattested wthompson"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2024-01-30","13859704","","2024-01-30","01/30/2024 CAQH Reattested wthompson"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-07-19","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","3041792","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 5/1/2019 PID # 3041792\ntisha rader"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-06","Location added under group record, but is not a Tricare Credentialed location. MS"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-03","1639524861","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1639524861","752656723","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-16","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 4/16/2019.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-07-19","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2023-12-27","12/27/2023 Priscilla Albertine at MQA sent follow-up email to Marcus Wester at Humana to try and get an updated and requested a roster.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-07-19","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1639524861","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2017-06-26","1639524861","","2020-08-03","8/3/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","","","2023-08-25","Confirmation of location being added via provider directory. MS"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15","1639524861","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","360348204","079837301","2020-01-29","01/29/2020 - found provider through payer portal. Provider is linked to the following plans: TRADITIONAL MEDICAID, Texas Children's Health Plan - MRSA Northeast, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-09-15","1639524861","","2020-09-22","09/22/2020 - Called 800-872-3862 but routed to Aetna Corporate Center and unable to reach live rep. Called Aetna @ 800-353-1232 S/W Mark. Provider NPI# is on file for the provider and is participating effective 09/15/2020 under the group and TIN#. Physical location is on file.Call Ref# 5560576876. - Archie Candiasan"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Ste. 240. MS"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","2017791","","2021-08-04","8/4/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 3/31/2021 with assigned provider ID number 2017791. KFrazier"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-01-05","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31","1639524861","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3-19-2020 - Rec'd email from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-07-19","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-08-01","1639524861","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-04","","","2023-08-21","Per TMHP website provider is active at 4214 Andrews Hwy Ste 107. Effective 08/04/2022. Jen Videan"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 10/15/2019.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-27","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is approved and participating under Group Tax ID and location effective 10/27/2020. Kimberly Frazier"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","1144665233","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-26",""]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","In House Enrollment","2019-09-01","842726","270548","2020-06-29","06/29/2020 - Rec'd a copy of the Medicare EFF letter for our records to support other payer enrollment. Medicare enrollment will be maintained in-house (not my Symplr) - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-09-08","09/08/2020 - Rec'd email from the payer stating:\n\"Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nW Gage Liesman, MD NPI: 1144665233\n5026 – West Texas Physicians Alliance – Eff Date 09/01/2019\n23655 – West Texas Physicians Alliance – Eff Date 09/01/2019\n52669 – West Texas Physicians Alliance – Eff Date 09/01/2019\" - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2019-09-30","1144665233","","2020-08-20","08/20/2020 - rec'd email from the payer stating this provider is affilliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. \nThis provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2024-01-31","","","2024-01-31","01/31/2024 CAQH Reattested wthompson"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2019-08-01","1144665233","","2020-06-12","06/12/2020 - Rec'd email from the payer stating this provider is EFF - PID# 3303866 - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2019-08-30","1144665233","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR, CHIP_PERINATAL, STAR_PLUS, CHIP.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-01-01","1144665233","","2020-08-31","08/31/2020 - moved to completed status after reviewing August follow up complete note - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","In House Enrollment","2019-09-01","404183201","","2020-06-29","06/29/2020 - client supplied us with copy of MEDICAID EFF letter for other payer enrollments, if needed. Symplr does not need to maintain this enrollment.  Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2019-10-01","1144665233","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","6694913","","2020-11-24","11/24/2020 - Per f/u report provider NPI# is on file for the provider is linked and is participating effective 09/01/2020 under the group and TIN#. Provider ID 6694913. Group ID 4907135.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-06-05","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-11-01","1932541406","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-30","13876531","","2024-01-30","01/30/2024 CAQH Reattested wthompson"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-30","13876531","","2024-01-30","01/30/2024 CAQH Reattested wthompson"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-30","13876531","","2024-01-30","01/30/2024 CAQH Reattested wthompson"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-30","13876531","","2024-01-30","01/30/2024 CAQH Reattested wthompson"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-06-05","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2019-07-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","IMS","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-06-05","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-07-01","5258891","","2023-08-16","8/16/2023 Per follow-up note - provider NPI# is on file for the provider and is participating effective 07/01/19 under the group and TIN#. Location address is on file. PIN# 5258891. DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-07-02","1932541406","","2020-09-14","Upon review of the Self-Service portal, provider is completed and loaded as participating under practice location. Kimberly Frazier"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-04-15","1932541406","","2020-07-30","7/30/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Rec'd email confirmation from Multiplan/Texas True Chioce stating EFF information is correct - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-07-20","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/20/2019.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-06-01","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2023.  PID # 3002056.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-06-05","","","2023-10-20","10/20/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-08-11","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-06-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-05","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-09-07","9/7/2023 Per email rcvd from Scott & White delegated roster for June has been completed.  Provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-07-20","1932541406","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 7-20-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","Omni PPO","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12","1932541406","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-08-14","1932541406","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 8-14-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-06-05","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-06-05","","","2023-08-01","8/1/2023 Rcvd email confirmation that provider is PAR and linked to group/location effective 6/5/2023.  PID # 7585417.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-08-11","","","2023-08-23","8/23/2023 Per Tricare portal provider is PAR and linked to group/location effective 8/11/2023."]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2019-05-01","397298601","079837301","2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-06-05","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is under DIRECT CONTRACT EFF 5-1-2019 - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-06-05","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-21","","","2023-09-06","Downloaded approval letter from TMHP website. Effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12","1932541406","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-06-14",""]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","","","","2024-03-14","Application submitted via TMHP. Request ID: 20443153. Your application has been submitted and is now under review. Your request number is: 20443153 Jen Videan Jen Videan"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-07-01","1811423981","","2020-09-09","09/09/2020 - moved to completed status after reviewing last note - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-08-30","1811423981","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - rec'd email from the payer Multiplan/Texas True Choie stating that this effective info is true - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-04-07","5847282","","2024-01-31","Received completion notice. MS"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-08-26","1811423981","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","1811423981","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-08-30","1811423981","752656723","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1811423981","","2020-07-19","7/19/2020 - Received email spredsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-26","1811423981","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12","1811423981","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-01-01","","","2020-10-30","10/30/2020 Provider is certified as non-network effective 1/1/2019, as she is currently participating under group Tax ID and location is being updated. Kimberly Frazier"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-06-01","1811423981","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 4/1/2022.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-06-15","6103957","","2020-06-08","06/08/2020 - Rec'd email from the payer stating this provider is PAR with the network effective 6/15/2020. Your Provider Identification Number (PIN) is: 6103957 - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-10-01","1811423981","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","Pending Info/Document","2023-10-04","14074150","","2023-10-04","10/04/2023 - Invalid Id and Password - Mkhan"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-08-26","1811423981","","2020-06-25",""]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-06-01","805590","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-10-23","","","2020-12-04","12/4/2020 Upon review of self-service portal provider is now participating under Group Tax ID and location. KFrazier"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-06-01","6730214","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-08-01","3304172","","2020-03-24","3/24/2020-receieved email with roster from payor stating provider PAR 8/1/2019 PID # 3304172\ntisha rader"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-07-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/1/2020.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","397315801","079837301","2020-01-29","01/29/2020 - found provider through payer portal. Provider is linked to these plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1255584397","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-08-26","1255584397","","2020-06-25",""]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.  DCannon"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-10-02","1255584397","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","Pending Info/Document","2023-01-09","","","2023-06-05","6/5/2023-Invalid CAQH Login-kavello"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-09-01","1255584397","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","1255584397","","2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is enrolled - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2019-07-01","P02326890","","2020-03-30","3/25/2020--Per online check, provider is now PAR effective 07/01/2019 with provider number P02326890. Attached welcome letter to payor line\ntisha rader"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2019-08-30","1255584397","830358685","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1255584397","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1255584397","","2020-07-02","7/2/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2020-06-29","1255584397","","2020-07-09","07/09/2020 - Rec'd welcome letter stating this provider is PAR with Amerigroup STAR, STAR PLUS & Star Kids products through Texas True Choice - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-02-19","408008701","","2020-04-07","04/07/2020 - Rec'd letter from the payer stating this provider has been approved with TRADITIONAL medicaid only. - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-01","1255584397","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer (Irma from First Care) that this provider is EFF as of 7/1/2019 and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2019-06-01","1255584397","","2020-11-02","11/2/2020 - Moved to completed status after reviewing follow up note - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2019-07-01","833803","519061","2020-02-20","02/20/2020 - Updated information with EFF letter rec'd from Medicare - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.  DCannon"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-08-06","1255584397","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-06-23","5186048","","2021-07-27","7/27/2021 Received an email from PDMnotification@cigna.com with confirmation of approval for participation effective 6/23/2021 with assigned provider ID 5186048. KFrazier"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2011-07-29","1255584397","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-08-26","1255584397","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-23","14530139","","2023-10-03","10/03/2023 - Updated license, Liability, added location and re-attested - rkedare"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1528619525","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","403199901","079837301","2020-01-29","01/29/2020 - Found provider through payer portal. Provider is par with Traditional Medicaid only - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1528619525","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-04-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-07-01","6345073","","2020-07-10","07/10/2020 - Rec'd EFF email from the payer stating \"Welcome to the provider network effective 7/1/2020. Your Provider Identification Number (PIN) is: 6345073\" - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1528619525","","2020-10-01","10/01/2020 - Rec'd an email from the payer stating this enrollment has been completed  - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1528619525","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-12-11","1528619525","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-03-06","Application in PE Review status. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-03-06","Application in PE Review status. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-03-06","Application in PE Review status. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-03-06","Application in PE Review status. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312274","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Sent email to LeNetrice Myart for a roster for the PriMed delegation agreement.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-10-01","869041","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-10-01","1528619525","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1528619525","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-01-01","09832854","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-01","1528619525","","2020-07-27","IMS complete"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-01","1528619525","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-04-02","1528619525","","2020-09-24","09/24/2020 - moved to completed after reviewing follow up complete - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-12-13","1528619525","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 12-13-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-12-30","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 12/30/2019.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-12-11","13706552","","2020-07-21","07/21/2020 - Rec'd spreadsheet from the payer stating this provider/TIN/service location are PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated  - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-12-30","1528619525","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 12-30-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Per Healthsmart provider portal provider is still not loaded under group TIN.  Provider still not updated will allow more time, check back in 2 weeks.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Receipt Validated","","","","2024-01-12","1/12/2024 Rcvd confirmation from UHC that January delegated roster has been received.  Submission Reference # PR-7975923.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-11-17","","","2024-02-13","Provider effective 11/17/2023. Alliance WC website only lists two locations per provider. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-30","1/30/2024 Per UHC portal provider load in Wellmed is still pending.  Will check back in a few days.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-07","Application to add this location to Medicare is still pending with Medicare. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-12-21",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-07","The group application to add this location was submitted and is still processing. Once the this location has been added at the group level, the provider will automatically be enrolled at this location as well. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2024-03-12","Emailed Texas Mutual (wwtxcontracts@texasmutual.com) for update on site visit. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-01","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","","","","2024-03-15",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-20","","","2024-03-05"," Per spneast@sedgwickcms.com address has been added to provider's profile effective 12/20/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-15","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-15","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-12-05","Rcvd Welcome letter. Provider effective 11/17/2023. See status updates under Alliance WC payor line.  Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-11-17","","","2023-11-27","Rcvd Welcome letter. Provider effective 11/17/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-09-01","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-09-01","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-09-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-10-13","13747034","","2020-12-23","12/23/2020 - Confirmed with HealthSmart that provider has been loaded effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-10-01","1J2798","0008AH","2020-11-18","11/18/2020 - Rcvd notification from Novitas that Change of Information app has been approved.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2020-10-13","","","2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2020-01-23","1276203","","2020-09-04","Confirmed provider is participating with PPO and H&W networks (see attached list of networks). Kimberly Frazier"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Amerigroup","Participating","Enrollment Complete","2020-02-13","1366762874","","2020-03-17","03/17/2020 - Rec'd email confirmation from the payer via a spreadsheet stating this provider is EFF at this service location - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak+"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2016-01-02","1366762874","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Rail Road Medicare","Participating","Enrollment Complete","2019-11-01","P02428265","DW7662","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through payer portal - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Medicaid","Participating","Enrollment Complete","2025-03-16","386007403","364596201","2020-08-13","8/13/2020 - signed onto TMHP and confirmed this provider is EFF and affilaited with the group - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-01-24","937962","","2023-12-12","After receiving surrogacy, the provider already linked under this TIN effective 1/24/2020. MS"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email rcvd from Karen Avalos at Galaxy December roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2022-08-07","","","2023-08-21","Stephanie Crawford  Medicaid par effective 08/07/22. Jen Videan"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","2022-12-19","3641811","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2023-02-14","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 2/14/2023.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2022-12-19","","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 11/28/2022.   DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","In Process","Application Submitted","","","","2024-03-15","Application submitted via TMHP. Request ID: 20443854. Jen Videan"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2020-05-06","1447882915"," West Texas Physician Alliance","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2014-11-01","P01415478","CE1588","2020-03-25","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2014 with provider number P01415478. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-07-29","1922008234","","2020-07-31","7/31/2020 - Rec'd an emaill from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Jul 29, 2020 11:53:03 AM. Your request was assigned reference number PR-5410462 .\" - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1922008234","","2020-11-02","11/2/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","154421503","079837301","2020-01-29","01/29/2020 - Found provider through payer portal. Provider is linked to the following plans: SUPERIOR - FOSTER CARE, FirstCare - Lubbock, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Superior Health Plan - Lubbock, Superior Health Plan - MRSA West, Amerigroup - MRSA West, Superior HealthPlan - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West, Superior Health Plan - MRSA West - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-04-25","1922008234","","2020-06-05","06/05/2016 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2014-06-04","1922008234","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 6-4-2014. Provider is networked with Beechstreet. - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2014-06-04","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 6/4/2014.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-07-31","7/31/2021 This will be processed by group. KFrazier"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 3/20/2020.   DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2018-04-23","1750796009","Midland Community Healthcare Services","2020-07-06","07/06/2020 - Rec'd email from the payer stating:\n\"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Jangangari, Swetha Reddy:\n\nNetwork:  MPI/PHCS\nNetwork Participation effective:4/23/2018 Contract Source Group contract through: Midland Community Healthcare Services\n\nAs for Beech Street the provider is not affiliated with Beech.  Due to integration, without an existing group contract with a Beech Street affiliation we would not credential providers with that particular provider network.\"  - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 3/20/2020.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2018-02-28","1750796009","","2020-06-26",""]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","595054YM2M","00304W","2020-09-22","9/22/2020 - rec'd email from the clinic stating this service location has been approved by the group medicaid enrollment - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1447701602","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this service location has been added - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","2020-06-11","13952422","","2020-06-11","06/11/2020 - Provider did not supply CAQH login. Provider will maintain this info in-house - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2017-04-01","1447701602","","2020-09-24","09/24/2020 - moved to enrollment complete status - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2017-01-31","1447701602","","2020-06-04","06/24/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","1547832","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 1547832. KFrazier"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2018-08-03","1447701602","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) has sent confirmation that this provider is EFF with Amerigroup - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2017-02-10","1447701602","","2020-06-30","6/30/2020 - Received email spreadsheet from the payor confirmaing that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2017-01-31","1447701602","","2020-06-04","06/24/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2018-11-06","1154767234","","2020-08-19","8/19/2020 - Rec'd email confirmation from the payer stating this provider IS LINKED TO THE PRIMED DELEGATED AGREEMENT under this TIN/Service Locaiton. Provider is networked with the following: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Rail Road Medicare","Participating","Enrollment Complete","2015-05-05","P02500765","DC8592","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through the site - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2020-03-20","","","2022-04-13","4/13/2022 Per roster from IMS/Omni provider is PAR and linked to group TIN/location effective 3/20/2020.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-08-30","1154767234","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2017-01-01","1154767234","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2017-01-01","1154767234","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-07-07","0392062","","2020-07-08","07/08/2020 - Rec'd email from the payer stating \"Your effective date is 07/07/2020. Your provider identification number is 0392062.\"  - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2015-10-07","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 10/7/2015.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-10-07","1154767234","","2020-10-30","10/30/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Oct 7, 2020 12:05:19 PM. Your request was assigned reference number PR-5533533 .\" - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-09-04","2327745","","2022-02-04","2/4/2022 Per roster received from First Health provider is PAR and linked to group TIN/location effective 9/4/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-06-15","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2019-06-05","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 6/5/2019.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-05-01","","","2022-04-09","4/9/2022 Per roster received from Galaxy provider is listed as PAR and linked to group TIN/location effective 5/1/2020.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-02-20","1891931341","","2020-06-04","06/04/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","9085264","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 9085264  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2019-02-20","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/20/2019.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-09-04","3313543","","2022-02-04","2/4/2022 Per roster received from First Health provider is PAR and linked to group TIN/location effective 9/4/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.   DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2020-01-15","","","2022-10-20","10/20/2022 Rcvd email from Priscilla Albertine at MQA with roster from Marcie Eckhart-Havens at Multiplan with confirmation that provider is PAR w/ Molina under group TIN/location effective 1/15/2020.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","522362","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 522362. KFrazier"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","In House Enrollment","","","","2021-08-04","7/31/2021 This will be processed by group. KFrazier"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2020-01-01","","","2020-12-04","12/4/2020 Confirmed provider is certified as non-network provider under group. KFrazier"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 3/20/2020.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1184265050","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.   DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-08-03","9835482","","2020-08-04","8/4/2020 - Rec'd email from the payer stating \"Your effective date is 08/03/2020. Your provider identification number is 9835482. \" - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 06/01/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2019-10-24","888038","00304W","2020-06-23","06/23/2020 - Rec'd proof of enrollment from the clinic by way of welcome letter - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04","8/3/2021 Medicaid enrollment is done in-house by MCHS.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","IMS","Participating","Enrollment Complete","2022-06-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","Cigna","Participating","Enrollment Complete","2022-06-01","3332103","","2022-05-26","5/26/2022 Rcvd email from Cigna that providers new location has been added and linked to group TIN effective 6/1/2022.  PID # 3332103.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Omni PPO","Participating","Enrollment Complete","2021-08-09","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 8/9/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","USA PPO","Participating","Enrollment Complete","2021-08-09","","","2021-12-03","12/32021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/9/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","Aetna","Participating","Enrollment Complete","2022-06-01","","","2022-06-02","6/2/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 6/1/2022.   DCannon"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-10-09","415097101","","2020-10-20","10/20/2020 - signed onto group TMHP account and found that this provider is now effective and linked to the group at this service location - Stacey Hudak"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312270","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Sent email to LeNetrice Myart for a roster for the PriMed delegation agreement.  DCannon"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2019-09-01","","","2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 9/1/2019.  DCannon"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-06-23","","","2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 6/23/2020.  DCannon"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2020-06-03","13729769","","2020-07-24","07/24/2020 - Rec'd spreadsheet from the payer stating this provider/service location/TIN are all affiliated under the PRIMED DELEGATED contract - Stacey Hudak"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-05-16","1750539268","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-04-22","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 4/22/2020.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Per Healthsmart provider portal provider is still not loaded under group TIN.  Provider still not updated will allow more time, check back in 2 weeks.   DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-10-19","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 10/19/2017.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-27","7/27/2023 Rcvd email confirmation from Cigna that this group and Tax ID 47-3465832 are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the providers do not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-12-21","12/21/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-09-19","9/19/2023  Provider is PAR and linked to group/locations effective 6/1/2020.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2018-11-30","1528430865","473465832","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-06","","","2024-03-06","03/06/2024 CAQH Reattested wthompson"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/05/2023. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/05/2023. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2018-12-15","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 12/15/2018.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-11","Provider is active at 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-11","Provider is active at 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2018-10-01","715814","","2020-06-15","06/15/2020 - Provider is effective per spreadsheet rec'd from the clinic - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2018-10-01","715814","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 10/1/2018.  PID # 715814.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-23","Provider is linked to the Briarwood location effective 7/28. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-23","Provider is linked to the Briarwood location effective 7/28. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location is completed effective 10/9/2023. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","1528430865","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2018-11-30","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 11/30/2018.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-12-28","12/28/2023 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of delegated roster submission.   DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2020-05-06","13727511","","2020-07-21","07/21/2020 - Rec'd emailed spreadsheet from the payer stating this provider/service location/TIN are EFF under WEST TEXAS PHYSICIANS ALLIANCE Delegated agreement - Stacey Hudak"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","Galaxy Health","Participating","Enrollment Complete","2021-07-06","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective 7/6/2021.  DCannon"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-01","1518053149","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","Omni PPO","Participating","Enrollment Complete","2021-07-06","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 7/6/2021.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","IMS","Participating","Enrollment Complete","2023-07-15","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1922328079","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Wellcare","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","ADA Adult and Children Family Clinic LLC","Amerigroup","Participating","Enrollment Complete","2019-09-18","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/18/2019.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","ADA Adult and Children Family Clinic LLC","Amerigroup","Participating","Enrollment Complete","2019-09-18","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/18/2019.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating under delegation effective 8/1/2020. Kimberly Frazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2020-10-24","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating under Group Tax ID and location effective 10/24/2020. Kimberly Frazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2020-08-24","1F6412","320497","2020-08-13","8/13/2020 - Rec'd email from the payer stating this has been approved. Signed into PECOS to confirm - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2019-12-13","","","2023-05-02","5/2.2023 Per confirm par status -  Per rep, provider is showing participating with an effective date 12/13/2019 and link under the Group and TIN. Provider ID 2343457.  Service location is on file. Call ref#:610334. DCannon"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, TIN has active 400TX DCN.  TIN has association of RHC."]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2017-03-30","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 3/30/2017.  DCannon"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2019-12-13","1225277833","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Texas Mutual","Participating","Enrollment Complete","2023-05-01","","","2023-05-10","5/10/2023 Rcvd TX Mutual - WorkWell approval letter.  Provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","In Process","Payor Follow Up","","","","2024-02-29","Pending Texas Mutual site visit. Per MQA, site visit is scheduled for 03/05/2024. Jen Videan"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2024-03-06","Emailed contracting@careworks.com, SPNEAST@sedgwickcms.com and shedeh.hale@sedgwick.com for status. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2017-10-18","","","2023-05-02","5/2.2023 Per confirm par status - Per rep, provider is showing participating with an effective date 10/18/2017 and link under the Group and TIN. Provider ID 2939545.  Service location is on file. Call ref#:610334. DCannon"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2016-10-26","","","2020-09-14",""]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2016-10-19","1972942209","","2020-07-01","07/01/2020 - Rec'd confirmation from the payer via email that this provider is EFF - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","In Process","Payor Follow Up","","","","2024-02-29","Pending Texas Mutual site visit. Per MQA, site visit is scheduled for 03/05/2024. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-27","Check Coventry portal for enrollment status. MS"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Participating","Enrollment Complete","","","","2024-02-01","Per Coventry portal provider is enrolled. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Texas Mutual","Participating","Enrollment Complete","2023-11-01","","","2023-11-20","Rcvd approval ltr. Provider effective 11/01/2023. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2020-07-14","04223193","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","","RHC PART A ONLY","","2020-07-28","07/28/2020 - THIS SERVICE LOCATION AND GROUP NPI IS FOR AN RHC FACILITY (part A) only. \n\nThere is no provider link/reassignment for this group.\n\nThis provider is active with Medicare, but cannot be reassigned to this TIN/Group NPI. It bills under facility only, not by provider.  Moved to completed status to remove from work list - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Texas Mutual","In Process","Payor Follow Up","","","","2024-02-29","Pending Texas Mutual site visit. Per MQA, site visit is scheduled for 03/05/2024. Jen Videan"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Check Coventry portal for enrollment status. Provider currently not showing as active. MS"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-01","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2019-01-25","","","2021-05-09","5/9/2021 Upon review of the self-service portal, provider's recredentialing is complete and enrollment effective 1/25/2019. KFrazier"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2017-02-20","560166YTA9","0A3812","2020-09-25","09/25/2020 - moved to completed status after reviewing PECOS EFF info from the clinic - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-13","11/14/22 Per Scarlett Abigail, TIN has active 400TX DCN.  TIN has association of RHC."]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Check Coventry portal for enrollment status. Provider currently not showing as active. Jen Videan"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2010-01-15","","","2023-05-02","5/2.2023 Per confirm par status -  Per rep, provider is showing participating with an effective date 1/15/2010 and link under the Group and TIN. Provider ID 2099013.  Service location is on file. Call ref#:610334. DCannon"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2019-11-01","","","2021-01-18","1/18/2021 - Per follow-up notes provider NPI# is on file for the provider and is participating effective 11/01/2019 for Commercial Choice, 08/02/2017 for Community and State and 06/01/2020 for Medicare under the group and TIN#.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2015-01-01","","","2021-07-09","7/9/2021 Called Humana at 800-626-2741 spoke w/ Taylor, call reference # 2000191481297 he confirmed that provider is PAR under TIN and location effective 1/1/2015.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-02-01","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Check Coventry portal for enrollment status. Provider currently not showing as active. Jen Videan"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-12-26","1669617981","","2020-08-31","8/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2022-03-02","","","2024-03-06",""]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","7004909","","2020-09-08","09/08/2020 - Reviewed the last note and the spreadsheet sent by the payer. THis can be made EFF - Stacey Hudak"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-04-12","","","2021-04-12","4/12/2021 Received email from Latisha Green at Latisha.Green@wpsic.com with written confirmation of certification approval under group Tax ID and location, effective 3/12/2021, and assigned TERV ID 752656723 79701 X012. KFrazier"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-05-10","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2021-05-10","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2024-01-24","","","2024-01-24","01/24/2024 CAQH Reattested wthompson"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2017-04-01","1720353592","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-02","","","2020-08-20","08/20/2020 - Rec'd spreadsheet back from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT Under this TIN/Service Location. Provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2020-08-22","1184035313","","2020-10-23","10/23/2020 -Called the payer and spoke with Corrine and was told that this provider HAS BEEN DE-DELEGATED AS OF 6-19-2020 and currently holds a direct contract with UHC. Provider is linked to this TIN as of 8-22-2020. - Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2020-09-01","","","2020-10-30","10/30/2020 Confirmed via self-service portal provider is participating under group Tax ID and location effective 9/1/2020. However, she is currently in the recredentialing process, which is why it states 'action needed'. KFrazier"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2020-08-05","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Participating","Enrollment Complete","2022-10-01","","","2022-11-11","11/11/22 Confirmed participating effective date 10/1/22 per Scarlett Abigail"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2018-07-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 7/1/2018.  DCannon"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2022-10-04","","","2024-03-06","Re-Cred completed effective 10/4/2022. MS"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1306928098","","2020-08-21",""]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1306928098","","2020-08-21",""]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Texas Mutual","Participating","Enrollment Complete","2020-07-02","","","2021-01-23","11/25/2020-Confirmed provider is participating under group Tax ID and practice location. -Elonah Grace B. Gelig"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2011-11-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 11/01/2011.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2017-01-01","1306928098","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-11-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 11/01/2011.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Boon Chapman","Participating","Enrollment Complete","2016-07-07","1306928098","","2020-10-05","Enrolled thru PHCS"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2016-10-01","","","2022-10-06","09/28/2022 - Received Permian Physician Services Roster from TriWest VA (Scarlett Abigail,  scarlett_abigail@bcbstx.com); provider listed as participating, effective 10/01/2016 | Priscilla A."]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Triwest VA","Participating","Enrollment Complete","2016-10-01","","","2022-10-06","09/28/2022 - Received Permian Physician Services Roster from TriWest VA (Scarlett Abigail,  scarlett_abigail@bcbstx.com); provider listed as participating, effective 10/01/2016 | Priscilla A."]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","","","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","Sedgwick","Pending Other Enrollment","Pending Contracting","","1161265","","2024-03-06","Emailed contracting@careworks.com, SPNEAST@sedgwickcms.com and shedeh.hale@sedgwick.com for status. Jen Videan"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2018-03-01","1184626749","","2020-07-30","7/30/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","United Health Care","Participating","Enrollment Complete","2020-10-29","754025","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 10/29/2020 and assigned provider ID 754025. KFrazier"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","2023-01-19","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 12/1/2022. Location is on file. Provider ID is 3625881. Next recredentialing date is every 3 years (12/1/2025) No information for the payer#. -Kim Monique Fabian"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Maria Montero, MD",1508218843,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2020-11-05","","","2021-05-09","5/9/2021 Upon review of the self-service portal, provider is participating under group Tax ID and location effective 11/5/2020. Also states action needed, which is typically the payor notification to process a new back-ground check. KFrazier"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Participating","Enrollment Complete","2013-12-25","333694YSCJ","290001","2020-07-31","07/31/2020 - was able to log into group enrollment for Quick Care and confirm that this provider is linked to the correct group PTAN/service location - Stacey Hudak"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2013-11-01","","","2020-12-24","12/24/2020 Provider is certified as non-network provider under Group Tax ID and location. KFrazier"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-10-12","1H6228","0008AH","2020-11-23","11/23/2020 Provider has been approved under group PTAN and issued PTAN 1H6228 effective 10/12/2020. Kimberly Frazier"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-10-08","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-11-08","","","2021-11-30","11/30/21 Per Tricare portal, provider added to location. Cbankston"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-12-14","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/14/2020.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-09-17","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2020-09-17","","","2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2023-01-19","1.19.2023 S/W Ashanti of First Health @ 800-226-5116. Transferred the call and spoke with Stacey. Provider is on file and participating. Link under the group and TIN effective 12/1/2022. Location is on file. Provider ID is 3634130. Next recredentialing date is every 3 years (12/1/2025). No information for the payer#. -Kim Monique Fabian"]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-06-01","6615260","","2021-07-08","7/1/2021-S/W Jessie of AETNA @ 8003531232, NPI# of the provider is on file and shows link and PAR under the group and TIN# effective 6/1/2021, physical location is on file. Provider ID is 6615260.  As per Rep, Rep confirmed that once provider is credentialed w/ Aetna automatically, provider is also credentialed w/First Health and Coventry. Call ref#6028231587."]
["Rachel Ann Murphy, RD",1124637160,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rachel Ann Murphy, RD",1124637160,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-12-07","","","2021-08-01","8/1/2021 Per Mary Rodriguez w/ Caprock provider is PAR and linked to group TIN/locations effective 12/7/2020.  DCannon"]
["Rachel Ann Murphy, RD",1124637160,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-12-07","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 12/7/2020.   DCannon"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2022-02-25","","","2022-03-09","3/9/2022 Per Tricare portal, provider is linked to location as of 2/25/2022. Cbankston"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","Boon Chapman","Participating","Enrollment Complete","2021-09-02","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective  9/2/2021. DCannon"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-03-01","3/1/2021 Rcvd confirmation that provider is participating with Healthsmart PPO effective 1/7/2021.  DCannon"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-10-09","10/9/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 1/7/2021.  DCannon"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2021-04-01","7338412","","2021-04-02","4/2/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating effective 4/1/2021 with assigned provider ID 7338412. KFrazier"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-17","","","2023-10-19","10/19/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/17/2023.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","CAQH","Provider Load","CAQH Reattested","2024-01-19","","","2024-01-19","CAQH reattested updated and uploaded liability. 01/19/2023 wthompson"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"75-2656723","TX","","Triwest VA","In House Enrollment","Application Submitted","","","","","08/19/2022 - Submitted application to TriWest VA (sent to Scarlett Abigail, Scarlett_Abigail@bcbstx.com)"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-01-07","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 1/7/2021.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-03-01","3/1/2021 Rcvd confirmation that provider is participating with Healthsmart PPO effective 1/7/2021.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-12","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","USA PPO","Participating","Enrollment Complete","2021-01-07","1310973","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Multiplan","Participating","Enrollment Complete","2021-01-07","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2021-01-07","","","2021-03-26","3/26/2021 Rcvd confirmation email from Jamie Roberts that February delegation roster adds have been completed.  DCannon"]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2021-09-02","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 9/2/2021.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2020-11-04","1M2870","519061","2021-02-18","2/18/2021 Received Medicare approval notice with assigned PTAN 1M2870, effective 11/14/2020. KFrazier"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2021-02-08","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/8/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2021-02-08","Q00052513","DW7662","2021-04-07","4/7/2021 Rcvd automatic approval of RR Medicare PTAN via web submittal.  PTAN # Q00052513 effective 2/8/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Re-Credentialing","2021-03-15","","","","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-03-15","","","2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 3/15/2021.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2022-12-01","","","2023-02-28","2/28/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 12/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Rail Road Medicare","No Enrollment Required","No Enrollment Required","","","","2021-04-09","4/8/2021 No enrollment required due to this being a RHC.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","No Enrollment Required","No Enrollment Required","2021-04-01","","","2021-04-08","4/8/2021 Enrollment is not required due to practice being an RHC. KFrazier"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2022-12-01","3629097","","2023-01-19","01.19.2023 S/W Kurtney of First Health @ 800-226-5116. Per rep, provider is showing participating with an Effective date 12/01/2022 and link under the Group and TIN. Provider ID 3629097, Payer ID 73159 and Recredentialing date 12/01/2025. Service location is on file. Call ref#:517643. -Danico Gabriel Melendres"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","IMS","Participating","Enrollment Complete","2022-12-01","","","2023-01-05","1/5/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 12/1/2022.   DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2022-12-01","2M8579","0A3812","2022-12-28","12/28/2022 Rcvd copy of Medicare approval letter.  Provider is PAR and linked to group effective 12/1/2022.  PTAN # 2M8579.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2021-04-06","","","2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 4/6/2021.  DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2021-07-09","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/9/2021.  DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-29","","","2024-01-29","01/29/2024 CAQH Reattested wthompson"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","Medicaid","In House Enrollment","In House Enrollment","2021-07-01","1417309105","","2021-09-21","9/21/2021 Per email received from Candace Wynne she has submitted the TMHP application for provider.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2022-03-23","","","2022-06-11","6/11/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 3/23/2022.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-05-10","","","2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2021-05-10","","","2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-05-10","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2021-05-10","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Kristin M Moose, FNP",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","CAQH","Participating","CAQH Reattested","2023-12-12","","","2023-12-12","12/12/2023  CAQH Reattested added one location"]
["Kristin M Moose, FNP",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending Multiplan enrollment.  DCannon"]
["Emily Baker, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-08-09","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 8/9/2021.  DCannon"]
["Emily Baker, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-10-01","13951752","","2022-02-24","2/24/2022 Per follow-up note from 2/18/2022 - Per rep, NPI# is on file for the provider and is participating effective 10/01/2021 under the group and TIN#. Physical location is on file. Provider ID is 13951752. Call ref # 7919532. - DCannon"]
["Emily Baker, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2021-08-01","1R7343","0008AH","2021-07-21","7/21/2021 Received Medicare PTAN approval letter.  PTAN # 1R7343 - effective 8/1/2021 DCannon"]
["Emily Baker, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2021-08-01","3478844","","2021-11-15","11/15/2021 Per f/u note S/w Regine of First Health @ 800-226-5116. Provider NPI# is on file for the provider and is participating effective 08/01/2021 under the group and TIN#. PIN 3478844. Physical location is on file. DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-12-20",""]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-12-20",""]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-07-19","PR-6183946","","2021-11-01","11/1/2021 Received an email from united_healthcare_provider_operations@uhc.com confirming provider is now participating under group Tax ID effective 7/19/2021 with assigned provider ID 007017728, which was processed under reference number PR-6183946. KFrazier"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-07-01","Q00126646","DX4335","2021-09-03","9/3/2021 Upon application submitted, received assigned RR PTAN Q00126646 effective 7/1/2021 under group RR PTAN DX4335. KFrazier"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-19","Eastridge eff 10/9/23, Briarwood eff. 10/9/23 and Longview eff. 7/10/21 locations are all approved. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-19","Eastridge eff 10/9/23, Briarwood eff. 10/9/23 and Longview eff. 7/10/21 locations are all approved. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Revalidation completed. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2021-10-08","","","2024-02-15","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2023-09-05","9/5/2023 Per email from Priscilla Albertine at MQA she received a roster confirming that provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-01","9/1/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-24","Re-Cred completed. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-08-13","","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from August has been completed and provider is PAR effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-07-16","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 7/16/2020.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-07-16","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 7/16/2020.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-09-01","3642314","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 9/1/2021.  PID #3642314.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-12-21","","","2023-12-21","12/21/2023 CAQH reviewed - added new location - 616 N. Main St.  Profile re-attested.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-12-06","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 12/06/2021. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-12-06","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 12/06/2021. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2024-03-05","Per SPNEAST@sedgwickcms.com, your providers’ credentialing has been received & is currently under review at this time. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-06","007274702","","2023-09-07","9/7/2023 Per email received from Priscilla Albertine at MQA provider is PAR and linked to group TIN/location effective 9/6/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Superior","Participating","Enrollment Complete","2023-04-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","Galaxy Health","Participating","Enrollment Complete","2021-08-13","","","2021-10-06","10/6/2021 Rcvd email from Karen Avalos at Galaxy confirming that the August delegated roser provider load has been completed and providers are loaded under TIN/locations effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","United Health Care","Participating","Enrollment Complete","2019-11-14","","","2022-02-22","2/22/2022 Received email from NMRT networkhelp@uhc.com, provider is par with location as of 11/14/2019. Cbankston"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","Medicaid","Participating","Enrollment Complete","2021-07-22","405626904","","2021-08-09","8/9/2021 Upon review of the self-service portal, provider has been approved with assigned TPI 405626904 effective 7/22/2021 and revalidation due 7/22/2026. KFrazier"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Aetna","Participating","Enrollment Complete","2021-09-15","","","2021-10-29","10/29/2021 Per email from Mary Hanna at Aetna provider is PAR and linked to group TIN and location effective 9/15/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Cigna","Participating","Enrollment Complete","2021-11-01","9076378","","2021-11-03","11.3.21 Received email DiscoverCigna@information.cigna.com. Application to participate in the Cigna network has been approved. Effective date is 11/01/2021. Provider identification number is 9076378. Cbankston"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-01","","","2023-01-05","1/5/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 8/1/2022.   DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2021-11-18","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 11/18/2021.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-06-06","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/6/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-09-07","9/7/2023 Per email rcvd from Scott & White delegated roster for June has bee completed.  Provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2021-12-01","6898581","","2022-02-24","2/24/2022 Per follow-up note from 2/17/2022 Provider NPI# is on file for the provider and is participating effective 12/1/21 under the group and TIN#. PIN 6898581. Physical location is on file. Ref# 6075329217. -DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-01","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 8/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-11-18","","","2022-04-21","4/21/2022 Per email received from VYoung at Humana delegated roster for December has been completed and providers loaded in Humana effective 11/18/2021.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-08-01","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 8/1/2022.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2021-11-01","12182506","","2022-03-25","3/25/2022 Per Amerigroup online directory provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2021-12-01","","","2022-04-18","4/18/2022 Per Superior Validation roster provider is PAR and linked to group/location effective 12/1/2021.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2021-10-29","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 10/29/2021. DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-10-29","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 10/29/2021.  DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2021-12-22","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 12/22/2021.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-11-18","","","2022-03-29","3/29/2022  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 11/18/2021.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-11-18","","","2022-04-21","4/21/2022 Per email received from VYoung at Humana delegated roster for December has been completed and providers loaded in Humana effective 11/18/2021.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-11-18","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 11/18/2021.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-01-29","","","2024-01-29","01/29/2024 CAQH Reattested wthompson"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","No Enrollment Required","2021-12-01","","","2021-11-09","11/9/2021 Provider is currently certified as non-network so no application is needed. KFrazier"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-08","008166599","","2023-10-27","10/27/2023 Received email confirmation from Priscilla Albertine and UHC that effective date has been corrected to 9/8/2023.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","Panel Closed","Panel Closed","","","","2023-12-22","Per Karina Garcia TIN is not in contract. Submit roster and W9 and she will send to nominations for review. \n\nThank you for your interest in joining the network. I heard back from nominations and we are panel full. We do keep the nominations on file for a year incase there are any openings. I have attached the panel full letter for your records.\nJen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-11-01","","","2023-11-14","Approval Ltr rcvd. Provider effective 11/01/2023. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2024-01-16","Per Melody Starcher mstarcher@permianregional.com, Permian Physician Services and Andrews Family Medicine have  decided not to sign a contract  with Corvel. Jen Videan"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Texas Municipal League","Enrollment Stopped","Enrollment Denied","","","","2023-12-14","See Alliance WC payor line status. Jen Videan"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-02-01","Per Coventry portal provider currently not showing as active. Add to next delegated roster. Jen Videan"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-03-04","2E5656","0008AH","2022-06-13","6/13/2022 Rcvd Medicare approval letter.  PTAN # 2E5656 - effective 3/4/2022.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01","2763424","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID # 2763424.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-06-01","5835766","","2022-05-18","5/18/2022 Rcvd email from Aetna that provider is PAR and linked to group TIN/locations effective 6/1/2022.  PID # 5835766.  DCannon"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-05-06","","","2024-02-07","Provider is showing active at this location eff 3.10.2022. MS"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-07-01","5154560","","2022-06-19","6/19/2022 Per email received from Aetna provider is PAR and linked to group TIN effective 7/1/2022.  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-06-21","6/21/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Rail Road Medicare","Participating","Enrollment Complete","2022-04-26","Q00295742","EA8735","2022-07-21","7/21/2022 Received RR Medicare approval letter.  PTAN # Q00295742 effective 4/26/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 6/1/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-07","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-07","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-07-19","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/19/2023.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-07-19","008051513","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 7/19/2023.  MPIN# 008051513.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-13","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/13/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2023-08-24","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2023-07-27","7/27/2023 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-09-06","","","2023-09-19","Received completion email. Eff 9/6/2023 MS"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2022-09-16","","","2022-09-27","9/27/2022 Rcvd PSWCA - Alliance approval letter.  Provider is PAR and linked to group TIN effective 9/16/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2022-03-14","1790251031","","2024-02-08","Approval letter rcvd. Effective 03/14/2022. Jen Videan"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/09/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-18",""]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-06-02","6/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No action provider will need to complete initial credentialing prior to adding CCN. Please resubmit your request to add CCN once provider has fully Initial Credentialing.\""]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-08-09","","","2022-08-09","8/9/2022 Rcvd Corvel approval letter.  Provider is PAR and linked to group TIN/locations effective 8/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2022-09-16","","","2022-09-27","9/27/2022 Rcvd PSWCA - Alliance approval letter.  Provider is PAR and linked to group TIN effective 9/16/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-05-09","007929415","","2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/9/2022.   MPIN# 007929415.   DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-05-09","3558012","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/9/2022.  PID# 3558012  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-26",""]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-07-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/24/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-05-09","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-06-29","","","2022-07-14","7/14/2022 Per Humana Military provider portal provider is PAR and linked to group TIN/location effective 6/29/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-05-09","6689991","","2022-06-21","6/21/2022 Per follow-up note - S/w Joan of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 05/09/2022  under the group and TIN#. PIN: 6689991. Physical location is on file. Call ref# 6094998732. - DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-04-05","6841061","","2022-06-21","6/21/2022 Per follow-up note - NPI# for the provider is on file shows link and Par under the group and TIN# effective 4/5/2022, the physical location is on file and the Provider ID is 6841061.  Call ref # Angel6142022. - DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-05-09","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 5/9/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-08-15","","","2022-10-10","10/10/2022 Per roster received from Scott & White provider is PAR and linked to TIN effective 8/15/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-20","","","2023-10-23","10/23/2023 Per roster received from USA PPO provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","USA PPO","Participating","Enrollment Complete","2022-06-20","","","2023-10-23","10/23/2023 Per roster received from USA PPO provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Cigna","Participating","Enrollment Complete","2022-05-01","0461877","","2022-07-15","7/15/2022 Per confirm par status note on 6/3/2022 - S/W Frank at Cigna, who confirmed provider is credentialed in TX through a delegation and is linked to tax ID as of 5/1/2022. Provider ID is 0461877. Ref # is frank 6/3/2022. HSmith"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Cigna Healthspring","In Process","Add Info Submitted","","","","2024-03-05","Payor requested a group W9. This was submitted via email. MS"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2022-09-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-12-17","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 12/17/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-08-25","","","2022-09-06","9/6/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 8/25/2022.    DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2022-08-25","","","2022-09-06","9/6/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 8/25/2022.    DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-08-15","6692236","","2022-10-11","10/11/2022 Per email from Cigna provider is PAR and linked to group TIN/location effective 8/15/2022.  PID# 6692236.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for September is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2022-06-20","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01","","","2022-08-10","8/10/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2022-07-18","1568704971","","2022-08-22","8/22/2022 Per TX Medicaid web portal, provider is PAR and linked to group effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-06-20","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-07-18","2G1495","0008AH","2022-07-21","7/21/2022 Rcvd Medicare approval letter.  PTAN # 2G1495 - effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-06-20","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1871250191","","2022-10-20","10/20/2022 Rcvd TMHP approval letter provider is PAR effective 8/28/2022.  TPI # 1871250191.  DCannon"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-07","","","2022-10-10","10/10/2022 Per email frmo Scott & White provider is PAR and linked to group TIN effective 10/7/2022.  DCannon"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-09-26","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/26/2022.   DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3284256","","2023-07-25","7/25/2023 Per email response from First Health provider is PAR and linked to group effective 11/1/2022.   Billing and mailing address on file are correct.  PID # 3284256 DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Rail Road Medicare","Participating","Enrollment Complete","2023-01-25","P02703383","","2023-08-21","Confirmed enrollment. MS"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Triwest VA","Participating","Enrollment Complete","2022-10-15","","","2022-10-05","10/05/2022 - Received email from Linda Navejar (Linda_Navejar@bcbstx.com) informing provider is participating within TriWest VA's network, effective 10/15/2022."]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-01-01","","","2022-12-13","12/13/2022 Per email received from Priscilla Albertine at MQA provider is PAR and linked to group TIN/locations effective 1/1/2023.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-05-07","2H3685","0008AH","2022-08-18","8/18/2022 Rcvd Medicare approval letter.  PTAN # 2H3685 - effective 5/7/2022.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-12-27","","","2022-12-13","12/13/2022 Rcvd email from Scott & White that provider is PAR and linked to group TIN/locations effective 12/27/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3637702","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID #3637702.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-09-12","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/1/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 5/1/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-11-27","Per Karina Garcia at Corvel, Ramon Lujan, NP NPI: 1205572716- credentialing approved since 01/18/2023, renewal 01/18/2026. For billing purposes we always reflect back to the contract date which for this group is 7/20/2020. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed the provider is loaded at the Briarwood location effective 9/20/2023. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Revalidation completed. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Revalidation completed. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Revalidation completed. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-02","","","2024-02-02","02/02/2024 CAQH Reattested wthompson"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 5/1/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Ramon Lujan. Effective 12/05/2023. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-01","9/1/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-01-06","","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-11-27","Provider is active at 6950 Eastridge and 4705 Briarwood. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-05-01","","","2023-09-27","9/27/2023 Per email response from Marcus Wester at Humana May delegated roster has bee completed.  Provider is PAR and linked to group/location effective 5/1/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-04",""]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-10-02","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-10-18","","","2024-03-05","Per spneast@sedgwickcms.com address has been added to provider's profile effective 10/18/2023. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-10-01","","","2022-10-26","10/26/2022 Rcvd Rail Road Medicare approval letter.  PTAN # Q00353706 - effective 10/1/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-10-01","","","2022-10-26","10/26/2022 Rcvd Rail Road Medicare approval letter.  PTAN # Q00353706 - effective 10/1/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","Participating","Enrollment Complete","2022-08-31","1972946648","","2022-09-14","9/14/2022 Per email from Denisse Villa at MCHS provider is PAR in TX Medicaid effective 8/31/2022.  TPI # 1972946648.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","2022-11-18","Provider Type Not Applicable"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-08-29","","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-08-29","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-08-29","","","2022-11-04","11.04.2022 Per follow-up note - S/W Chealse of Amerigroup @ 800-454-3730. Per rep, provider is showing participating with an  Effective date 08/29/2022 and link under the Group and TIN. Provider ID 14501240, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-166745338.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-11-01","","","2023-02-15","02.15.2023 S/W Shannon of First Health @800-226-5116. Per rep, provider is in network and linked under the TIN effective 11/01/2022. Don't have next recredentialing date. Provider ID# 1972946648. Physical location is on file. Don't have payer#. Unable to obtain call ref# since rep transferred me to a different department. - Mary Rose Acebedo"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-08-29","8664296","","2022-10-18","10/18/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN effective 8/29/2022.  PID # 8664296.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-08-29","8664296","","2022-10-18","10/18/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN effective 8/29/2022.  PID # 8664296.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-08-29","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-10-01","","","2022-12-19","12/19/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-08-29","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for September is complete.  Provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-08-29","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2022-10-01","","","2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-08-29","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-15","","","2022-10-10","10/10/2022 Per roster received from Scott & White provider is PAR and linked to TIN effective 10/15/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-08-29","","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-08-29","","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-07-18","9246114","","2022-10-26","10/26/2022 Rcvd email from CIGNA that provider is PAR and linked to group TIN/locations effective 7/18/2022.  PID # 9246114.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-02-13","all locations - panel closed, locations are not prime credentialed. MS"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-02-13","all locations - panel closed, locations are not prime credentialed. MS"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-10-01","","","2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-11-01","0914108","","2022-11-15","11/15/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 11/1/2022.  PID # 0914108.  DCannon"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-11-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-10-10","","","2022-12-31","12/31/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for October has been completed.  Provider is PAR and linked to group TIN effective 10/10/2022.  DCannon"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-10-10","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 10/10/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","IMS","Participating","Enrollment Complete","2022-09-26","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/26/2022.   DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2022-09-26","","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 9/26/2022.  PID# 14643274.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2022-09-26","14614970","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 9/26/2022.  PID# 14614970.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-11-14","","","2023-02-09","2/9/2023 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/14/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2022-09-26","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-12-11","Permian Physician Services would like to hold off contracting with Broadspire at this time. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2022-09-26","","","2022-12-29","12/29/2022 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-10-31","","","2023-03-08","3/8/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for November has been completed.  Provider is PAR and linked to group TIN effective 10/31/2022.   DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-31","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from November has been completed and provider is PAR effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-10-31","","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 10/31/2022.  PID# 14835000.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-10-31","","","2022-12-31","12/31/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for November has been completed.  Provider is PAR and linked to group TIN effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-12-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-10-31","","","2023-02-25","2/25/2023 Per email received from Vernita Young November delegated roster has been processed and provider is PAR effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-12-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-10-31","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-10-31","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-10-31","","","2022-12-15","12.15.22 Called Aetna @800.353.1232 and spoke with rep. Gelo who confirmed provider is participating effective 10/31/2022 at service locations and Tax ID. No recred date given per rep. Provider # 8624593. Call ref# 6124264748. ABoles"]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Ambetter","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending Multiplan enrollment.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2023-02-06","1558971432","","2023-07-19","7/19/2023 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for February has been completed.  Provider is PAR and linked to group effective 2/6/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2023-03-01","1558971432","","2023-03-10","3/10/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 3/1/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete","2023-02-01","3649598","","2023-12-27","12/27/2023 Per follow-up note -  Per rep, Provider is in network with First Health for the state of TX and linked to the group and TIN# effective 02/01/2023. Rep transferred me over to the next rep and spoke to Brenda. Next recredentialing date is on 02/01/2026. Per rep, they don't provide PIN#. Rep advised to visit First Health website. Upon checking First Health website location is on file.  PIN# is 3649598. DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2023-02-06","1558971432","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 2/6/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2024-01-08","9337042","","2024-01-09","Received confirmation email. MS"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-03-15","1558971432","","2023-08-22","8/22/2023 Per email from Scott & White provider is PAR and linked to group TIN/location effective 3/15/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2023-03-13","1558971432","","2024-02-28","Recredentialing has been completed. Eff 3/13/2023. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-01-31","","","2024-02-01","Received welcome letter. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-12-04","6K6786","423838","2024-02-27","Received welcome letter from MCR. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-22","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023 Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-01","","","2024-03-01","03/01/2024 CAQH Reattested added one practice location wthompson"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-07","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-07","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-09-07","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-07","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-07","9/7/2023 Panel is closed for enrollment.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-07","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-01","","","2023-12-18","See status updates under Alliance WC payor line. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-12-04","Q00683125","DX4335","2024-03-07","Confirmed provider is linked to this record. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-12-04","Q00683125","DX4335","2024-03-07","Confirmed provider is linked to this record. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-15","Sacha Stanley, NP added to contract with WesTex with an effective date of 5/23/23. \nJen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-07","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/7/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-12-28","12/28/2023 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of delegated roster submission.   DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-06-01","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-07","3694275","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/7/2023. Provider ID 3694275. Physical locations are on file. Call ref#:773026. - DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-07","3694275","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/7/2023. Provider ID 3694275. Physical locations are on file. Call ref#:773026. - DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-06-01","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-01","008733826","","2024-01-30","1/30/2024 Rcvd email confirmation from UHC that January delegated roster has been completed.  Provider is PAR and linked to group/location effective 2/1/2024.  MPIN # 008733826.   DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-01","","","2023-12-18","Welcome ltr rcvd. Provider effective 12/01/2023. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-01","","","2023-12-18","Welcome ltr rcvd. Provider effective 12/01/2023. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-06-01","008733826","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 6/1/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-19","","","","Received confirmation provider is enrolled and participating with the following networks, eff. 10/19/2023:\nBAV - Blue Advantage HMO\t,\nHME - Health Select,\nBCA - BlueChoice PPO,\nHMO - Blue Essentials, and\nPMC - Medicare Advantage PPO\t\n- PA"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed provider is linked to Longview location effective 9/20/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed provider is linked to Longview location effective 9/20/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location has been confirmed eff 10/9/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location has been confirmed eff 10/9/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location has been confirmed eff 10/9/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-07","8439204","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/07/2023. No next recredentialing date available. PIN: 8439204. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-07","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-08-25","8/25/2023 Per email received from Caprock provider has been added to new locations  4705 Briarwood Ave and 6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-12-20","","","2023-12-20","12/20/2023 CAQH reviewed - added new location - 616 N. Main Street.  Profile re-attested.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-08-25","8/25/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Per Healthsmart provider portal provider is still not loaded under group TIN.  Provider still not updated will allow more time, check back in 2 weeks.   DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-06-09","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 06/09/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-15","5/15/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-06-09","","","2024-02-16","Per Michelle Killough @ Alliance WC provider is effective 06/09/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-05-01","","","2023-09-27","9/27/2023 Per email response from Marcus Wester at Humana May delegated roster has bee completed.  Provider is PAR and linked to group/location effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-12-19","Group has Ancillary contract where all midlevel services are billed under the group contract rather than Ind. claims. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-04-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 4/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an active ancillary contract, so credentialing for midlevels isn't required. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-15",""]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-01","","","2023-10-26","Eastridge location approved effective 10/9/2023. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-03-31","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 3/31/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","3592528","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W Longview Ave and 6950 Eastridge. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W Longview Ave and 6950 Eastridge. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-03-31","3671302","","2023-09-01","9/1/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 3/31/2023.  PID # 3671302.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-01","","","2023-09-26","Confirmation of Longview location effective 9/1/2023. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, so no credentialing is required for midlevels. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-03-31","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 3/31/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-06-26","007726107","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 6/26/2023.  MPIN # 007726107.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-12-28","12/28/2023 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of delegated roster submission.   DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2024-03-05","Emailed spneast@sedgwickcms.com and providerdata@careworks.com for status. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment updates. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-09-06","Rcvd approval letter from Karina Garcia. Effective 08/21/2023 for 210 W Longview, 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-03-17","2V9975","","2023-08-25","Per PECOS provider is PAR and linked to group/locations effective 3/17/2023.  PID # 2V9975.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-24","Per Benjamin Richbourg, roster has been successfully loaded. They do not have effective dates for individual providers. The only effective date is the one on the contract. For this contract effective date is 05/23/2023. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge Rd Odessa, TX 79765, 4705 Briarwood Ave Midland, TX 79707 and 210 West Longview Avenue Suite A Building A\nMidland, TX 79701 effective 08/01/2023. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge Rd Odessa, TX 79765, 4705 Briarwood Ave Midland, TX 79707 and 210 West Longview Avenue Suite A Building A\nMidland, TX 79701 effective 08/01/2023. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-12-19",""]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-07-28","","","2023-07-31","07/31/2023, PA: Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO, Medicare Advantage PPO and Health Select, effective 07/28/2023."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-03-03","Q00521328","DX4335","2023-07-27","7/27/2023 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group effective 3/3/2023. PID # Q00521328.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2024-03-12","Emailed Texas Mutual (wwtxcontracts@texasmutual.com) for update on site visit. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-11-17","","","2023-11-27","Rcvd Welcome letter. Provider effective 11/17/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-12-05","See Alliance WC payor line for details. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-07","Application to add this location to Medicare is still pending with Medicare. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-05-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-05-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-08-01","","","2023-07-31","07/31/2023, PA: Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO,  Medicare Advantage PPO and Health Select, effective 08/01/2023"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-12-19","Group holds a ancillary contract, which bills services through the group. The midlevels do not require enrollment. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-01",""]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-11-17","","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-12-20","","","2023-12-20","12/20/2023 CAQH reviewed - added new location - 616 N. Main Street.  Profile re-attested.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-10-18","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W. Longview Ave and 6950 Eastridge. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-05-01","007509811","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 5/1/2023.  MPIN # 007509811.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-07-12","","","2023-07-12","Received email confirmation from Jacki Hipolito. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-12","Panel is currently closed."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Wellmed","Participating","Enrollment Complete","2023-05-08","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 5/8/2023.    DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-06-15","","","2023-08-08","Per response from hpdelegation@bswhealth.org, Dr. Daye  is effective 06/15/2023. Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to group delegated roster effective 6/1/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2023-05-08","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Omni PPO","Participating","Enrollment Complete","2023-05-08","","","2023-07-19","7/19/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-24","7/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-05-24","Confirmed via the HM portal. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Payor Follow Up","2023-06-01","","","2023-12-27","12/27/2023 Priscilla Albertine at MQA sent follow-up email to Marcus Wester at Humana to try and get an updated and requested a roster.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-06-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-09-16","000887435","","2023-10-05","10/5/2023 Rcvd copy of participating network list with effective dates for provider.  Provider is PAR with UHC effective 9/16/2023.  (see copy of report uploaded in attachments) DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-08-21","Confirmed enrollment. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2W8694","","2023-11-27","Received approval letter for ICR effective 10/2/2023. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-11-15","2840278","","2023-11-30","Received enrollment confirmation. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-08-08","Per response from hpdelegation@bswhealth.org, Dr. Hayne is effective 07/20/2023. Jen Videan"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-06-01","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-14","","","2023-08-31","8/31/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","4160673","","2023-08-04","8/4/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 4160673 DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","4160673","","2023-08-04","8/4/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 4160673 DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-08","","","2023-10-26","Eastridge location approved eff 10/9/23. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-08","","","2023-08-23","Confirmation the provider has been linked to the Briarwood and Longview locations. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-08","","","2023-10-26","Eastridge location approved eff 10/9/23. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-04-29","","","2023-08-21","Confirmed enrollment. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-11-15","","","2023-11-27","Rcvd approval letter. Provider effective 11/15/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-08-01","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-08-01","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Per Healthsmart provider portal provider is still not loaded under group TIN.  Provider still not updated will allow more time, check back in 2 weeks.   DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-18","","","2023-09-21","Per Michelle Killough provider is effective 08/18/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. Provider is not currently enrolled. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Enrollment Complete","2023-08-01","","","2024-01-25","1/25/2024 Per Amerigroup web portal provider is PAR and linked to group TIN/locations - 210 W. Longview Ave, Suite A, 4705 Briarwood Ave and 6950 Eastridge Ave effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","2023-08-01","","","2024-01-25","1/25/2024 6301 Andrews Hwy still pending.  Allow more time for processing.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-08-01","","","2024-01-31","1/31/2024 Per Humana provider portal provider is PAR and linked to group TIN/locations effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-08-01","","","2024-01-31","1/31/2024 Per Humana provider portal provider is PAR and linked to group TIN/locations effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal the provider is enrolled . MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","3607159","","2024-01-30","Confirmed via Coventry portal the provider is enrolled . MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-01-12","","","2024-01-12","01/12/2024 CAQH Reattested. Added one location and removed one."]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-08-01","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-08-01","00008830908","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 8/1/2023.   MPIN# 00008830908.   DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-10-26","Rcvd welcome letter from Karina Garcia at Corvel. Provider is effective 10/26/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-10-26","Rcvd welcome letter from Karina Garcia at Corvel. Provider is effective 10/26/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-04-29","","","2023-08-22","Confirmed provider is linked to all group locations. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","","","","2023-10-19","10/19/23 Enrollment complete and participating with all products.  Effective date 10/20/23"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-08-01","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-06-19","3674906","","2023-11-07","11.07.2023 S/W Teresa of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 06/19/2023. Provider ID 3674906. Service location is on file. Call ref#:810269. - Danico Gabriel Melendres"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal the provider is enrolled . MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-09","Per Benjamin Richbourg roster has been loaded and provider is effective 05/23/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-09","Per Benjamin Richbourg roster has been loaded and provider is effective 05/23/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-08-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-08-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal the provider is enrolled . MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","4705 Briarwood Ave Midland, TX 79707, 210 West Longview Avenue Suite A Building A\nMidland, TX 79701 and 6950 Eastridge Rd\nOdessa, TX 79765 effective 09/01/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","4705 Briarwood Ave Midland, TX 79707, 210 West Longview Avenue Suite A Building A\nMidland, TX 79701 and 6950 Eastridge Rd\nOdessa, TX 79765 effective 09/01/2023. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-12","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-12","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-06-12","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-01-24","Provider is loaded to Briarwood (eff 8/24/23)."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-05","Provider has been linked to Eastridge 10/9/23, Longview 8/24/23 and Andrews Hwy.  1/10/24  MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-05","Provider has been linked to Eastridge 10/9/23, Longview 8/24/23 and Andrews Hwy.  1/10/24  MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-06-10","Q00596481","DX4335","2023-11-08","Received enrollment confirmation. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-06-10","Q00596481","DX4335","2023-11-08","Received enrollment confirmation. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-01-29","","","2024-01-29","01/29/2024 CAQH Reattested wthompson"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-01-29","","","2024-01-29","01/29/2024 CAQH Reattested wthompson"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-12","9695700","","2023-10-24","10.24.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 06/12/2023. Next recredentialing date is 06/12/2026. PIN: 9695700. Servicing location is on file. Payer# 60054. Call ref# 6167813673. - Willie Ravas"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-12-28","12/28/2023 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of delegated roster submission.   DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 7/20/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 7/20/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 08/25/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 08/25/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-06-10","","","2023-09-21",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-10","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/10/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2024-02-16","Per Michelle Killough @ Alliance WC provider is effective 08/25/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-29","","","2024-01-04","Rcvd welcome letter. Provider is effective 12/29/2023. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-07","The group application to add this location was submitted and is still processing. Once the this location has been added at the group level, the provider will automatically be enrolled at this location as well. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-08-19","003289309","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/19/2023.  MPIN # 003289309.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-12","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-04",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-24","Per Benjamin Richbourg, roster has been successfully loaded. They do not have effective dates for individual providers. The only effective date is the one on the contract. For this contract effective date is 05/23/2023. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-06-01","2243378","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 06/01/2023. Provider ID 2243378. Physical locations are on file. Call ref#:773026. - DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-06-12","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Facility Enrollment","","","","2023-09-13","Rep confirmed there is an ancillary contract in place. Ancillary provider are not required to be enrolled individually. Claims are bill through the group. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-06-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-06-01","","","2024-01-22","1/22/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 6/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2024-02-01","13954674","","2024-02-01","02/01/2024 CAQH Reattested wthompson"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Participating","Enrollment Complete","2023-05-29","1073983193","","2024-01-16","Approval letter rcvd. Dana Bell is effective at 5424 19th St Ste 300 Lubbock TX effective 05/29/2023. Jen Videan"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","1073983193","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","Participating","Enrollment Complete","2023-08-12","006397593","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 8/12/2023.  MPIN # 006397593.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","HealthSmart PPO","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete","2023-05-29","Q00516460","CF8499","2023-07-19","7/19/2023 Rcvd RR Medicare approval letter.   PTAN # Q00516460 - effective 5/29/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Galaxy Health","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","Participating","Enrollment Complete","2023-08-01","19103471","","2024-01-09","1/9/2024 Per Amerigroup web portal provider is PAR and linked to Lubbock location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","667985783","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Participating","Enrollment Complete","2023-08-12","006397593","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 8/12/2023.  MPIN # 006397593.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2023-05-29","853821","","2024-02-12","Received completion notice. MS"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","In Process","Payor Follow Up","","","","2024-03-08","3/8/24 - called First Health & spoke w/ supervisor Brenda. Per Brenda, directed to resubmit request to pdsdallas@aetna.com. Request submitted. PA."]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Participating","Enrollment Complete","2023-06-22","","","2024-01-29","Received approval for 19th St. location eff 7/26/2023. MS"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2023-12-19","Per MQA, I received verbal confirmation from the practice, they are currently not desiring enrollment with WC payors. Please discontinue pursuit until further notice. Jen Videan"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","CAQH","Participating","CAQH Reattested","2024-02-26","","","2024-02-26","02/26/2024 CAQH Reattested updated and uploaded board and DEA"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","IMS","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-08-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Amerigroup","Participating","Enrollment Complete","2023-08-01","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Humana","In Process","Payor Escalated","","","","2023-12-07","12/7/2023 Sent follow-up email to Marcus Wester at Humana requesting update.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Aetna","Participating","Enrollment Complete","2023-08-01","4929401","","2023-09-19","09.19.2023 S/W IceB of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 08/01/2023. PIN: 4929401. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163752278. - Willie Ravas"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Multiplan","Participating","Enrollment Complete","2023-08-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Broadspire Services Inc.","In Process","Pending Contracting","","","","2024-03-05","Emailed providerrelations@primehealthservices.com for status. Jen Videan"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2023-09-08","","","2024-01-22","1/22/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/8/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2023-09-08","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Humana","In Process","Payor Follow Up","","","","2023-12-27","12/27/2023 Priscilla Albertine at MQA sent follow-up email to Marcus Wester at Humana to try and get an updated and requested a roster.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-03","","","2023-10-09","10/9/2023 Per email received from Scott & White provider is PAR and linked to group effective 10/3/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2023-09-19","007700003","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 9/19/2023.  MPIN# 007700003.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-09-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-19","","","2023-10-19","10/19/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2023-09-25","","","2023-11-03","Providers specialty has been approved. MS"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-19","Received confirmation of approval. MS"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2023-11-13","1972003119","","2023-12-15","12/15/2023 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 11/13/2023.  TPI # 1972003119.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2023-09-08","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/8/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2023-11-13","Q00602404","","2023-11-16","Received confirmation. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-07-10","008760942","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 7/10/2023.  MPIN # 008760942.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-07-20","Q00602406","DX4335","2023-11-16","notes are on other payor lines. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-11","","","2023-12-18","Welcome letter rcvd. Provider effective 12/11/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-07-10","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-07-10","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to locations/TIN effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-07-10","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to locations/TIN effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-07-10","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-08-31","8/31/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2023-09-01","","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-07-10","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-10","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","4705 Briarwood Ave, 210 West Longview Ave Ste A Bldg A and 6950 Eastridge  are effective 09/01/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-07-10","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-24","Credentialing Complete. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-12-21","12/21/2023 We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2023-09-28","Per Michelle Killough provider is effective 08/25/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-29","008760942","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 9/29/2023.  MPIN # 008760942.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Per Healthsmart provider portal provider is still not loaded under group TIN.  Provider still not updated will allow more time, check back in 2 weeks.   DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-07-10","","","2024-01-31","1/31/2024 Per Humana provider portal provider is PAR and linked to group TIN/locations effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-16",""]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-01-17","Per providerrelations@primehealthservices.comYour request has been received and being processed accordingly. However, at this time, I have no updates as to when the directory will be updated with the location add. \nPlease note, all Physicians/locations billing under the TIN you provided are subject to the terms of the PPO agreement and considered in network upon billing with the TIN.  Contract effective date 05/23/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W Longview Ave and 6950 Eastridge. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W Longview Ave and 6950 Eastridge. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-12-28","12/28/2023 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of delegated roster submission.   DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Facility Enrollment","","","","2023-09-13","Rep confirmed there is an ancillary contract in place. Ancillary provider are not required to be enrolled individually. Claims are bill through the group. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-10-26","Eastridge location confirmed effective 10/9/2023. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-10-26","Eastridge location confirmed effective 10/9/2023. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/2023. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/2023. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-19","","","2023-10-19","10/19/2023 Enrollment had to be resubmitted, new effective date for all products is 10/19/23. NGaneshraj"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-19","","","2023-10-19","10/19/2023 Enrollment had to be resubmitted, new effective date for all products is 10/19/23. NGaneshraj"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-08","15954818","","2024-03-08","03/08/2024 CAQH Reattested wthompson"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-16",""]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-07-10","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-07-10","8683782","","2023-09-19","09.19.2023 S/W IceB of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 07/10/2023. PIN: 8683782. Physical locations are on file. No next recredentialing date available. Payer# 60054. Call ref# 6163752278. - Willie Ravas"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-07-10","8683782","","2023-09-19","09.19.2023 S/W IceB of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 07/10/2023. PIN: 8683782. Physical locations are on file. No next recredentialing date available. Payer# 60054. Call ref# 6163752278. - Willie Ravas"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-08-22","008866025","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-10-06","","","2023-10-09","Received confirmation email. Attached. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-06-28","6/28/2023- per notification form, provider will maintain own CAQH - kavello"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2023-08-22","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2023-08-22"," 8574198","","2023-10-19","10.16.2023 S/W Anthony of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 08/22/2023. Provider ID 8574198. Service location is on file. Call ref#:6166954339.-Danico Gabriel Melendres"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-08-22","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-08-22","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-09-26","Provider has been loaded to the Andrews Hwy location effective 9/14/23. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-10-20","Provider is linked to Florida Ave location .MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-10-20","Provider is linked to the Rosalind location. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2023-08-22","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2024-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-09-29","0037","","2023-10-19","10.18.2023 S/W Kathy of TriCare Standard @ 1-800-444-5445 and transferred me over to the WPS Department and spoke to Shay. Per rep, Provider is certified with TriCare on 09/28/2023 and in network with Tricare and linked to the group and TIN# effective 02/20/2013. No next recredentialing date available. PIN: 0037. Servicing location is on file. Payer# trest. Call ref# Shay10182023."]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-08","","","2024-03-08","03/08/2024 CAQH Reattested wthompson"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2023-09-08","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","","","2023-09-05","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Effective 09/01/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Superior enrollment.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-08","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-08","008870743","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-08","008870743","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2023-10-01","","","2023-11-03","11/3/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","2Y3057","","2023-08-29","Received completed enrollment. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","","","2023-10-11","Received confirmation of enrollment attached. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-08","6474406","","2023-10-24","10.24.2023 S/W JoeO of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/08/2023. No next recredentialing date available. PIN: 6474406. Servicing location is on file. Payer# 60054. Call ref# 6167817975. - Willie Ravas"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-09-26","Confirmed Briarwood and Longview locations effective 8/23/23. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-11-05","Revalidation completed. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-09-26","Confirmed Briarwood and Longview locations effective 8/23/23. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-09-08","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-09-22","","","2024-02-16","Per Michelle Killough @ Alliance WC provider is effective 09/22/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-07","The group application to add this location was submitted and is still processing. Once the this location has been added at the group level, the provider will automatically be enrolled at this location as well. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with welcome letter from Karina Garcia effective 12/15/2023. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-01","008870743","","2024-01-30","1/30/2024 Rcvd email confirmation from UHC that January delegated roster has been completed.  Provider is PAR and linked to group/location effective 2/1/2024.  MPIN # 008870743.   DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-09-08","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-08","3746844","","2023-11-20","11/20/2023 S/W James of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/8/2023. Provider ID 3746844. Physical locations are on file. Call ref#:773110. - DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-12","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-12","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-09-08","","","2023-12-28","12/28/2023 Per Humana online web portal provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-11",""]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-08","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/8/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-12-21","12/21/2023 We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-08","","","2024-03-08","03/08/2024 CAQH Reattested wthompson"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-20","WTUC has an active Ancillary Contract in effect, which means any midlevel will not require credentialing and all services will be billed under the group contract. MS"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-10-09","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 10/9/2023.  DCannon"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-03-08","","","2024-03-08","03/08/2024 CAQH Reattested wthompson"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2023-12-05","9594034","","2024-01-02","Received confirmation of enrollment. MS"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023, and linked to TIN."]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete","2023-12-01","1083394977","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","In Process","Payor Escalated","","","","2024-02-28","Spoke with rep and she will not see any status updates for 90-120 days after the application was submitted to Medical Onboarding. She did advise me to email Medical Onboarding to see if they can provide an update. MS  Ref DELM 2/28/24 MS"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Participating","Enrollment Complete","2023-09-08","00020023935","","2024-01-29","1/29/2024 Per UHC provider portal provider is PAR and linked to group TIN/locations effective 9/8/2023. MPIN # 00020023935.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2023-09-08","1083394977","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","","United Health Care","Participating","Enrollment Complete","2023-09-08","008866169","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 9/8/2023.  MPIN # 008866169.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2024-01-29","16016463","","2024-01-29","01/29/2024 CAQH Reattested updated and uploaded liability wthompson"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2023-08-14","6B7029","","2023-10-24","Received welcome letter. MS"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete","2023-08-14","Q00595265","CF8499","2023-11-07","Received enrollment approval. MS"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-11-08","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/8/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-11-08","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 11/8/2023.  DCannon"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-04","Pending Aetna approval. MS"]
["Billy S Gao, MD",1699092304,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Billy S Gao, MD",1699092304,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-12-01","6E5297","","2023-12-05","Received approval letter effective 12/1/2023. MS"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2023-12-04","","","2024-01-22","1/22/2024 Per Aetna online portal provider is PAR and linked to group TIN/locations effective 12/4/2023.  DCannon"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2023-12-04","","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 12/4/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-09-18","9/18/13-Per notification form - provider will maintain - kavello"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and locations effective 11/06/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-11-06","006258398","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/6/2023. \nMPIN # 006258398.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-25","","","2023-10-27","Provider linked to Rosalind and Andrews Hwy location eff 9/28/2023. MS"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-20","Per the website, the panel is closed to new providers at this time. MS"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-20","Per the website, the panel is closed to new providers at this time. MS"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-30","1/30/2024 Per UHC portal provider load in Wellmed is still pending.  Will check back in a few days.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-10-01","Q00656144","","2024-02-05","Confirmed provider is enrolled eff 10/1/2023. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-10-01","Q00656144","","2024-02-05","Confirmed provider is enrolled eff 10/1/2023. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Welcome ltr rcvd. Provider effective 12/15/2023. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-16","Confirmed provider is linked to all Briarwood and Longview locations effective 10/9/23. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-16","Confirmed provider is linked to all Briarwood and Longview locations effective 10/9/23. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal provider is enrolled. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-01-22","1/22/2024 Still in process, need to allow more time.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Enrollment Complete","","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal provider is enrolled. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal provider is enrolled. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-21","","","2023-12-05","12/05/2023: Received email from Connie Traylor, stating \"Kristen Schlemeyer PA, is effective in Blue Choice PPO, Blue Essentials HMO, Health Select, Blue Advantage HMO, and Medicare Advantage PPO networks 11/21/2023. TIN ending in 5832.\" Copy of email uploaded. - PA"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal provider is enrolled. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-11-06","008766524","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/6/2023. \nMPIN # 008766524.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-11-06","00390311","","2024-01-29","1/29/2024 Per UHC provider portal probider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00390311.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-02-12","","","2024-02-13","Welcome ltr rcvd. Provider effective 02/12/2024. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-01-26","","","2024-01-26","1/26/2024 Reviewed and re-attested.  Updated current malpractice information and uploaded a copy of COI.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-04","Pending Aetna Approval. MS"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","2231549","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","2231549","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-15","","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-11-15","11/15/2023 Delegated roster submitted.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-11-06","003261515","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 003261515.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-11-06","003261515","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 003261515.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Longview location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Briarwood location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Briarwood location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Provider is loaded to the Eastridge location eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Longview location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2024-02-07","Confirmed provider is linked to Main St. location eff 1/19/2024. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2024-02-07","Confirmed provider is linked to Main St. location eff 1/19/2024. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2024-03-12","Emailed Texas Mutual (wwtxcontracts@texasmutual.com) for update on site visit. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023 and linked to locations:  4705 Briarwood, 6950 Eastridge  Rd, 6301 Andrews Hwy, and 210 Longview. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-16","Payor has closed the enrollment panel until further notice. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-01-26","","","2024-01-26","01/26/2025 CAQH Reattested wthompson"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Welcome letter rcvd. Provider effective 12/15/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-01-22","1/22/2024 Still in process, need to allow more time.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-04","Enrollment complete for 4705 Briarwood, 6950 Eastridge and 210 W Longview. Effective 12/01/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-11-06","00390310977","","2024-01-29","1/29/2024 Per UHC provider portal probider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00390310977.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-11-06","00390310977","","2024-01-29","1/29/2024 Per UHC provider portal probider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00390310977.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2024-03-05","Per spneast@sedgwickcms.com still in process. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-02-12","","","2024-02-13","Rcvd welcome letter. Provider effective 02/12/2024. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Per Healthsmart provider portal provider is still not loaded under group TIN.  Provider still not updated will allow more time, check back in 2 weeks.   DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-10-01","6C9153","","2023-11-08","Received welcome letter. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-25","","","2023-10-24","Received confirmation provider is enrolled and participating with the following networks, eff. 10/25/2023:\nBAV - Blue Advantage HMO\t,\nHME - Health Select,\nBCA - BlueChoice PPO,\nHMO - Blue Essentials, and\nPMC - Medicare Advantage PPO\n- PA"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-01-22","1/22/2024 Still in process, need to allow more time.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. Provider is not currently listed. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-01-30","1/30/2024 Rcvd email from Scott & White that December roster is still in process.  Please allow more time.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-18","Payor is not accepting new enrollments until further notice. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-01-19","","","2024-01-29","Alliance WC approval letter rcvd. Provider effective 01/19/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Payor Follow Up","","","","2024-01-16","1/16/2024 Sent follow-up email to Jessica Bess at Multiplan to check status of December roster.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-02-12","","","2024-02-13","Welcome ltr rcvd. Provider effective 02/12/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  Sent follow-up email to LaNetrice Myart to check status of December roster submission.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-22","","","2023-11-27","11/27/23: Received confirmation from BCBSTX per email, provider enrolled with the following networks, eff. 11/22/23:\nBAV - Blue Advantage HMO\nPMC - Medicare Advantage PPO\nBCA - BlueChoice PPO\t\nHME - Health Select\t\nHMO - Blue Essentials"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-22","","","2023-11-27","11/27/23: Received confirmation from BCBSTX per email, provider enrolled with the following networks, eff. 11/22/23:\nBAV - Blue Advantage HMO\nPMC - Medicare Advantage PPO\nBCA - BlueChoice PPO\t\nHME - Health Select\t\nHMO - Blue Essentials"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 12/04/2023 and linked to locations:  4705 Briarwood, 6950 Eastridge  Rd, 6301 Andrews Hwy, and 210 Longview. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 12/04/2023 and linked to locations:  4705 Briarwood, 6950 Eastridge  Rd, 6301 Andrews Hwy, and 210 Longview. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-12-04","","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 12/4/2023.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending Multiplan enrollment.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending Multiplan enrollment.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Longview, Briarwood, and Eastridge locations. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2024-02-28","02/27/2024 - received email confirmation from Dana Cannon/UHC,  stating case reference # CR-100000661176 has been completed. Per UHC report, provider is par, eff. 04/13/2024, but not tied to delegation.  Requested enrollment backdated, delegation clarification and location confirmations with Kelly Johnson of UHC. \nPA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-11-01","6E0916","","2023-11-29","Received approval letter effective 11/1/2023. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-12-15","12/15/2023 Delegated roster submitted.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-11","1/11/2024 Pending UHC enrollment.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-01-19","","","2024-01-29","Please see status updates under Alliance WC payor line. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-01","15380393","","2024-02-01","02/01/2024 CAQH Reattested updated DEA wthompson"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-01","15380393","","2024-02-01","02/01/2024 CAQH Reattested updated DEA wthompson"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Bailey Bergman, PA",1447851639,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-02-27","","","2024-03-13","Re-Cred completed. MS"]
["Bailey Bergman, PA",1447851639,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Provider Load","Provider Load","2024-02-09","","","2024-02-09",""]
["Bailey Bergman, PA",1447851639,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Provider Load","Provider Load","2024-02-09","","","2024-02-09",""]
["Bailey Bergman, PA",1447851639,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","In Process","Application Submitted","","","","2024-03-07","Application submitted, but needs more time to receive information from Medicare. Reference Number :\t24067001032  MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-01-30","1/30/2024 Rcvd email from Scott & White that December roster is still in process.  Please allow more time.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  Sent follow-up email to LaNetrice Myart to check status of December roster submission.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-12-04","","","2024-01-11","1/11/2024 Per email rcvd from Karen Avalos at Galaxy December roster is complete.  Provider is PAR and linked to group TIN/locations effective 12/4/2023.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-01-01","","","2024-01-18","Welcome letter rcvd. Provider is effective 01/01/2024. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-11","","","2023-12-18","Welcome ltr rcvd. Provider effective 12/11/2023 at 4705 Briarwood Ave, 6950 Eastridge Rd, 210 W. Longview Ave and 6301 Andrews Hwy. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-11","","","2023-12-18","Welcome ltr rcvd. Provider effective 12/11/2023 at 4705 Briarwood Ave, 6950 Eastridge Rd, 210 W. Longview Ave and 6301 Andrews Hwy. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-12-04","","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 12/4/2023.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2023-11-27","Per providerrelations@primehealthservices.com, provider has been uploaded to our system with an effective date of 05/23/2023. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-12-01","6E3444","","2023-12-04","Received enrollment welcome letter. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 12/04/2023 and linked to locations:  4705 Briarwood, 6950 Eastridge  Rd, 6301 Andrews Hwy, and 210 Longview. PA."]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 12/04/2023 and linked to locations:  4705 Briarwood, 6950 Eastridge  Rd, 6301 Andrews Hwy, and 210 Longview. PA."]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2023-11-14","","","2023-11-15","Panel is closed at the current time. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","","","","2024-01-24","Re-Cred for Briarwood is completed. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Payor Follow Up","","","","2024-03-07","Pending for Longview, Andrews Hwy, and Eastridge. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","","","","2024-01-24","Provider is enrolled with Briarwood location. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-01-22","1/22/2024 Still in process, need to allow more time.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-12-01","Q00640302c","DX4335","2024-01-12","Received confirmation of enrollment eff 12.1.2023 MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-12-11","00007286963","","2024-01-22","1/22/2024 Per UHC portal provider is PAR and linked to group TIN/location effective 12/11/2023. MPIN# 00007286963.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-12-15","12/15/2023 Delegated roster submitted.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Receipt Validated","","","","2024-02-26","Payor confirmed submission and if the request is approved, the contracting team will be reaching out. Enrollment is done by the group and not the individual provider.  Ticket 1440158. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Receipt Validated","","","","2024-02-26","Payor confirmed submission and if the request is approved, the contracting team will be reaching out. Enrollment is done by the group and not the individual provider.  Ticket 1440158. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-12-04","","","2024-01-22","1/22/2024 Per Aetna online portal provider is PAR and linked to group TIN/locations effective 12/4/2023.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Payor Follow Up","","","","2024-01-16","1/16/2024 Sent follow-up email to Jessica Bess at Multiplan to check status of December roster.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Superior enrollment.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-12-11","007286963","","2024-01-22","1/22/2024 Per UHC portal provider is PAR and linked to group TIN/location effective 12/11/2023. MPIN# 00007286963.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","3603341","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-29","","","2023-11-28","11/28/23- Received approval letter with effective date of 11/29/23."]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-29","","","2023-11-28","11/28/23- Received approval letter with effective date of 11/29/23."]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Welcome letter rcvd. Provider is effective 12/15/2023. Jen Videan"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Gerald Winemiller, APRN-NP",1316591522,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-01","","","2024-02-01","02/01/2024 CAQH Reattested wthompson"]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - Premier Family Care, Inc","BCBSTX","In House Enrollment","In House Enrollment","","","","2024-01-02",""]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","In Process","Payor Follow Up","","","","2024-02-23","Requested participation status, effective date and location confirmation from SHP (email sent to shpdelegation@superiorhealthplan.com); pending response. PA."]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Pending Other Enrollment","2023-12-13","6J8407","","2024-03-06","Individual enrollment pending add of Acute Care - Comprehensive Care Program to the group record. Jen Videan"]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Thru Other Payor","Payor Follow Up","","","","2024-02-23","Requested participation status, effective date and location confirmation from SHP (email sent to shpdelegation@superiorhealthplan.com); pending response. PA."]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-03-05","email sent to rep for enrollment update. MS"]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated roster on 2/15/2024. FC."]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2024-01-08","1/8/2024 Pending Superior enrollment.  DCannon"]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In Process","Application Submitted","","","","2024-02-21","Submitted application via email to Scarlett  Abigail (scarlett_abigail@bcbstx.com), along with COI."]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","In Process","Payor Follow Up","","","","2024-03-12","Per maria.lightner@careworks.com send roster with CAQHs, W9 and COIs. Requested information emailed to Maria. Jen Videan"]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Pending Other Enrollment","2024-02-07","","","2024-02-26","Payor confirmed submission and if the request is approved, the contracting team will be reaching out. Enrollment is done by the group and not the individual provider.  Ticket 1440158. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","2024-02-07","","","2024-03-12","Allow 180 days for processing. Submitted 02/08/2024. Still within timeframe. Allow more time. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","2024-02-07","","","2024-03-12","Please see status updates under Alliance WC payor line. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-02-12","Q00683123","DX4335","2024-03-07","Confirmed provider is enrolled. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-05","Provider has been linked to the Longview location eff 2/28/24. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-13","Provider is linked to Briarwood, Main St., Eastridge, and Andrews Hwy locations 3/5/24."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-13","Provider is linked to Briarwood, Main St., Eastridge, and Andrews Hwy locations 3/5/24."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-13","Provider is linked to Briarwood, Main St., Eastridge, and Andrews Hwy locations 3/5/24."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-02-07","","","2024-03-12","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Provider Load","Provider Load","2024-02-07","","","",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-02-07","","","2024-02-26","02/26/2024 - received email confirmation provider is par, eff. 02/27/2024, and added to the following networks: BAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-02-08","Location is not certified, so panel is closed to new providers. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-02-08","Location is not certified, so panel is closed to new providers. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","2024-02-07","","","2024-03-12","Per Michelle Killough at pswca provider has been approved to join network. Submit Provider Data Form and required documents. Emailed form and documents to Michelle. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-02-12","6K9986","","2024-02-29","Received welcome letter. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","2024-02-07","","","2024-03-12","Emailed wwtxcontracts@texasmutual.com for status. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","2024-02-07","","","2024-03-12","Emailed wwtxcontracts@texasmutual.com for status. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","2024-02-07","","","2024-03-13","Per Sedgwick, your providers’ credentialing is being processed by the CVO. If our CVO(Symplr) reaches out to you requesting additional information please respond. Credentialing can take up to 60 days. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","2024-02-07","","","2024-03-13","Per Sedgwick, your providers’ credentialing is being processed by the CVO. If our CVO(Symplr) reaches out to you requesting additional information please respond. Credentialing can take up to 60 days. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-02-12","TIN has a ancillary contract in place so midlevels do not require credentialing. Services are billed under the group contract, not the ind. provider. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2024-02-08","","","2024-02-08","02/08/2024 CAQH Sweep. Updated email, DEA, Board, Liability, work history, education, cred contact, and 5 practice locations. Uploaded docs. wthompson"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","2024-03-07","","","2024-03-11","Emailed TSCA and required documents to  wwtxcontracts@texasmutual.com. Jen Videan"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Briarwood location eff 3/7/2024. MS"]
["Caroline Clements, NP",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment on Hold","2024-03-07","","","2024-03-07","Eastridge, Andrews Hwy, Main St, and Longview locations can be added once Briarwood has been approved. MS"]
["Caroline Clements, NP",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Briarwood location eff 3/7/2024. MS"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Briarwood location eff 3/7/2024. MS"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Provider Load","Action Needed","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Provider Load","Provider Load","2024-03-07","","","",""]
["Caroline Clements, NP",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Application Submitted","","","","2024-03-11","Application submitted. T031120240005887  MS"]
["Caroline Clements, NP",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Application Submitted","","","","2024-03-11","Application submitted. T031120240005887  MS"]
["Caroline Clements, NP",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Receipt Validated","","","","2024-03-13","Received email stating the application has been received and is in review. Ref 13630227. MS"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-07","","","2024-03-07","03/07/2024 CAQH Sweep added 5 locations, cred contact, license, symplr email, and uploaded docs wthompson"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Application Submitted","","","","2024-03-08","Letter of Interest emailed. MS"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Application Submitted","","","","2024-03-08","Letter of Interest emailed. MS"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","2024-03-07","","","2024-03-11","Emailed TSCA and required documents to SPNEAST@sedgwickcms.com. Jen Videan"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-03-07","","","2024-03-12","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","2024-03-07","","","2024-03-11","Emailed roster to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","2024-03-07","","","2024-03-11","Application submitted via pswca.org. Jen Videan"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","2024-03-07","","","2024-03-11","Application submitted via pswca.org. Jen Videan"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-07","This TIN is not Tricare Credentialed, and the panel is closed to incoming requests. MS"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-07","This TIN is not Tricare Credentialed, and the panel is closed to incoming requests. MS"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-07","Pending Medicare approval. MS"]
["Caroline Clements, NP",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","2024-03-07","","","2024-03-11","Please see status updates under Alliance WC payor line. Jen Videan"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Sedgwick","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with WIN network in which this payor is included (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Liberty Mutual","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with WIN network in which this payor is included (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2024-01-24","12124562","","2024-01-24","01/24/2024 CAQH Reattested wthompson"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","First Health Coventry","Participating","Enrollment Complete","2023-02-01","3649611","","2023-03-08","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 02/01/2023. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3649611. Physical location is on file.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-29","1356484497","","2020-08-19","08/29/2020 - Rec'd spreadsheet back from the payer confirming that this provider is affiliated with the delegated PRIMED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1124009766","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","USA PPO","Participating","Enrollment Complete","2002-11-15","1124009766","752784378","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Aetna","Participating","Enrollment Complete","2012-05-01","1124009766","","2020-04-15","04/15/2020 - Rec'd response from follow up team stating \"S/W Nina of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 05/01/12 under the group and TIN with delegated contract with Primed health network. Physical location is on file. Call ref# 5225848462. \" - Stacey HUdak"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2024-01-31","","","2024-01-31","01/31/2024 CAQH REattested wthompson"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-04-14","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 4/14/2022.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-02","","","2024-01-09","Confirmed provider is linked to Ste. 271 via the self service portal. MS"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2022-02-01","","","2022-02-07","2/7/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 2/1/2022.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-12-06","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 12/06/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","1901-01-01","000466442","","2022-01-03","1/3/2022 Recevied email from asampat4@uhc.com, provider/group updates complete. Assigned reference number PR-6284499. Cbankston"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2021-12-06","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2021-12-06","","","2022-04-21","4/21/2022 Per email received from VYoung at Humana delegated roster for December has been completed and providers loaded in Humana effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-12-06","","","2022-03-11","03/11/2022  Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2021-12-06","","","2022-03-11","03/11/2022  Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","2024-02-28","Re-Cred has been completed. eff 1/2/2024. MS"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Amerigroup","Participating","Enrollment Complete","2016-08-04","1528000734","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) stating this provider is EFF at this service location with Amerigroup - Stacey Hudak"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Medicare","Participating","Enrollment Complete","1998-09-01","83461K","00320K","2020-04-20","04/20/2020 - Rec'd email stating this recred application was approved - Stacey Hudak"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2014-09-29","1659366433","","2020-03-25","3/25/2020--S/W Mary of Aetna @ 8003531232,  provider NPI# is on file for the provider and is participating effective 09/29/2014 under the group and TIN#. Physical location is on file. DIRECT CONTRACT --Call ref#: 5194781237. \nTISHA RADER"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2019-05-01","1659366433","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2017-04-15","1659366433","","2020-08-27","08/27/2020 - Rec'd email from the payer stating this provider is :  \"Thank you for contacting our Customer Service Department with Multiplan/PHCS. We received your request have confirmed that the following providers are participating with Multiplan and PHCS through Midland Pediatric Associates: - Willie Watson-Effective 04/15/2017\" - Stacey Hudak"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Per Healthsmart provider portal provider is still not loaded under group TIN.  Provider still not updated will allow more time, check back in 2 weeks.   DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Boon Chapman","Participating","Enrollment Complete","2021-01-07","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-11-27","Per Karina Garcia at Corvel, Lawrence Wilson, MD NPI: 1518951342- credentialing approved since 01/19/2022, renewal 01/19/2025. For billing purposes we always reflect back to the contract date which for this group is 7/20/2020. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-07-26","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-08-01","1103233","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/1/2021.  PID #1103233  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment updates. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment updates. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-07-26","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-01","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2021-11-16","002438204","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 11/16/2021.  MPIN # 002438204.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-01","","","2023-12-18","Welcome letter rcvd. Provider eff 12/01/2023. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2021-08-01","","","2021-10-08","10/8/21 Recevied email from CoventryProvider@cvty.us.com, provider effective 8/1/2021. Cbankston"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-02",""]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","In Process","Enrollment Complete","","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-07-26","","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from August has been completed and provider is PAR effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-12-03","12/3/2021 Per Amerigroup roster received Joe Rodriguez provider is PAR under group TIN/location effective 1/7/2021.   DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","IMS","Participating","Enrollment Complete","2021-01-07","","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-01-12","","","2023-11-27","11/27/2023 Updated mailing address for all WesTex locations.  WT"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-01-12","","","2023-11-27","11/27/2023 Updated mailing address for all WesTex locations.  WT"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-01-12","","","2024-01-12","1/12/2024 CAQH reviewed added new Wes Tex location - 616 N. Main St.  and re-attested.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-01-12","","","2023-11-27","11/27/2023 Updated mailing address for all WesTex locations.  WT"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-01-12","","","2024-01-12","1/12/2024 CAQH reviewed added new Wes Tex location - 616 N. Main St.  and re-attested.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-01-12","","","2024-01-12","1/12/2024 CAQH reviewed added new Wes Tex location - 616 N. Main St.  and re-attested.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Aetna","Participating","Enrollment Complete","2021-01-07","","","2021-06-28","6/28/2021 Received email response from aetnaproviderservices@aetna.com confirming provider is participating under group Tax ID and location effective 1/7/2021. KFrazier"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Medicare","Participating","No Enrollment Required","2020-12-01","1L5835","0008AH","2021-03-19","3/19/2021 There is no requirement to add additional location since provider is currently assigned PTAN under group. KFrazier"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2021-11-16","002438204","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 11/16/2021.  MPIN # 002438204.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location has been enrolled eff 10/9/23. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location has been enrolled eff 10/9/23. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-11-16","002438204","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 11/16/2021.  MPIN # 002438204.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-01","","","2023-12-18","See Alliance WC payor line for details. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","In House Enrollment","2020-07-22","","","2023-12-20",""]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","First Health Coventry","Participating","Enrollment Complete","2021-01-07","","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 1/7/2021.  PID # 1103233.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","In Process","Enrollment Complete","","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2020-09-01","1629074984","","2020-07-20","07/20/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Aetna","Participating","Enrollment Complete","2023-12-11","","","2024-01-22","1/22/2024 Per Aetna online portal provider is PAR and linked to group TIN/locations effective 12/11/2023.  DCannon"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Debbie P. Reese, MD PA","CAQH","Participating","CAQH Reattested","2024-03-08","","","2024-03-08","03/08/2024 CAQH Reattested wthompson"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1094380","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2008  PID # 1094380\ntisha rader"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2013-09-01","1907709","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 1907709 - Stacey Hudak"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2019-03-20","1942216122","","2020-08-19","08/19/2020 - Rec'd spreadsheet confirmation from the payer stating this provider is linked to the PRIMED DELEGATED CONTRACT with this TIN/Service Location and networked with the following: \nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2012-10-01","1942216122","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","United Health Care","Participating","Enrollment Complete","2020-03-01","1073555249","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1073555249","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Superior","Participating","Enrollment Complete","2020-08-01","1073555249","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-04-01","","","2023-08-22","Received confirmation. MS"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-10-18","3453380","","2023-10-19","Received enrollment confirmation. MS"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2023-05-25","","","2023-08-23","Confirmed provider is active and linked to location. MS"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2023-06-01","1119106","","2023-09-20","9/20/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2023.  PID #1119106.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-18",""]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2014-04-01","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2013-08-31","1013923291","","2020-06-25",""]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-01","","","2020-10-30","10/30/2020 Confirmed provider is certified as non-network under Tax ID and location. Kimberly Frazier"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2020-06-01","P02490186","CE1588","2020-08-28","08/28/2020 - found effective info through payer site - updated payer line - Stacey Hudak"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1679568380","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1098298","","2020-03-20","03/20/2020 - Rec'd an email from the payer stating this provider is EFF under this TIN. Email shared provider ID# 1098298 - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Liberty Mutual","Participating","Enrollment Complete","2009-10-23","1811900657","208658501","2020-08-19","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Medicare","Participating","Enrollment Complete","2007-11-01","8F6462","00Y323","2020-03-10","03/10/2020 - signed into PECOS and verified that this provider is linked to this group: SHYLESH GANTA ,MD , PA (group TPAN 00Y323) as of 11-1-2007 - Stacey Hudak"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1770564080","","2020-06-04","06/04/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Rail Road Medicare","Participating","Enrollment Complete","2013-04-01"," P01188488"," DT8096","2020-04-22","04/22/2020 - Verified proivder is EFF thorugh payer payer site - Stacey Hudak"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Medicaid","Participating","Enrollment Complete","","144105701","","2020-08-26","8/26/2020 - the clinic only provider an TPI number. I was not given an effective date. - Stacey Hudak"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Boon Chapman","Enrollment Stopped","Enrollment Stopped","","","","2023-10-16","10/16/2023 Provider is not enrolled in Multiplan, therefore, provider is not enrolled in Boon Chapman.  DCannon"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-13","1295724698","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-08-03","2026473","","2021-08-05","8/4/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 8/3/2021 with assigned provider number 2026473. KFrazier"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2002-10-01","1295724698","Multiple Group Affiliations","2020-04-09","04/09/2020 - Rec'd response from the payer stating:\n\"Thank you for contacting our Service Department at Multiplan/PHCS and Beech Street. Here is the following information we have on file for Patel, Kirit:\n\nNetwork: Multiplan\nNetwork Participation effective: 10/01/2004\nContract Source Group contract through: West Texas Physicians Alliance \n\nNetwork: PHCS\nNetwork Participation effective: 10/01/2002\nContract Source Group contract through: West Texas Physicians Alliance \n\nNetwork: Beech Street\nNetwork Participation effective: 01/01/2008\nContract Source Group contract through: West Texas Physicians Alliance\n\nNetwork: Multiplan and PHCS\nNetwork Participation effective: 02/28/2017\nContract Source Group contract through: Permian Basin Healthcare Network-Midlevel\n\nNetwork: Multiplan, PHCS, and Beech Street \nNetwork Participation effective: 11/01/2010\nContract Source : Individual\"\n\nStacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Liberty Mutual","Participating","Enrollment Complete","2011-09-01","1295724698","752656723","2020-08-19","Confirmed provider is participating with WIN network, which includes this payor (list of networks attached). Kimberly Frazier"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2018-08-14","1295724698","","2020-03-24","3/24/2020--S/W Erickof Aetna @ 18003531232, provider NPI# is on file for the provider and is participating effective 08/14/2018 under the group and TIN#. Physical location is on file. DIRECT CONTRACT--Call ref# 5192739438.\ntisha rader"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2011-09-01","1100846","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2011 PID # 1100846-tisha rader"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2020-04-03","","","2021-12-03","12/3/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/3/2020.  DCannon"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-13","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/13/2022.  DCannon"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","United Health Care","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-12-20",""]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-10-02","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2015-05-09","318466ZP5M","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/9/2015.  PID # 318466ZP5M.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2016-02-09","","","2024-01-11","Dr. Beck is effective at 210 W. Longview Ave Ste A, Bldg A Effective 02/09/2016. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2016-02-09","","","2024-01-11","Dr. Beck is effective at 210 W. Longview Ave Ste A, Bldg A Effective 02/09/2016. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2016-01-14","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 1/14/2016.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/05/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/05/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2020-04-15","","","2023-09-29","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 4/15/2020.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 1/8/2024.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-31","1912991084","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-11","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-07","The group application to add this location was submitted and is still processing. Once the this location has been added at the group level, the provider will automatically be enrolled at this location as well. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2009-01-01","1912991084","","2020-08-20","08/20/2020 - Rec'd email from the payer stating this provider is affiliated with PRIMED DELEGATED AGREEMENT under this TIN/Service Location. \nThe provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-12-20","","","2023-12-20","12/20/2023 CAQH reviewed - new location - 616 N. Main Street added.  Profile re-attested.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-08-02","","","2023-09-26","Per providerdata@careworks.com all three locations added Effective 08/02/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2015-05-09","P01841282","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2015-05-09","P01841282","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI August delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2016-02-19","","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-12-28","12/28/2023 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of delegated roster submission.   DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2016-01-14","","","2023-12-21","12/21/2023 - Per Jessica Bess at Multiplan provider is PAR and linked to group TIN/locations effective 1/14/2016.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider linked to Andrews Hwy location eff 10.26.2023"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider linked to Andrews Hwy location eff 10.26.2023"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2015-09-01","","","2023-08-18","8/18/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 9/1/2015.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2015-09-01","","","2023-08-18","8/18/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 9/1/2015.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2015-07-28","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 7/28/2015.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","2013-04-01","2230880","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 4/1/2013. KFrazier"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2023-05-04","5/4/2023 Per email from UHC delegated roster from February has been processed.  Provider is PAR and linked to group TIN effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Enrollment Complete","2004-10-01","1578557468","","2022-10-03","10/3/2022 Per TMHP web portal provider is PAR and linked to group effective 10/1/2004.  TPI# 1578557468.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-09-12","Q00346339","CE1588","2022-10-15","10/15/2022 Rcvd RR Medicare approval letter.  PTAN # Q00346339 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2022-09-13",""]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-11-28","11/28/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-09-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-11-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-09-12","","","2022-12-29","12/29/2022 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-09-12","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-10-10","","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 10/10/2022.  PID# 14614726.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-30","","","2024-01-30","01/30/2024 CAQH Reattested wthompson"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-09-12","2I8228","0008AH","2022-09-21","9/21/2022 Rcvd Medicare approval letter from Candace Wynne.  PTAN # 2I8228 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Vincent P Rascon, DPM",1346236924,"91-1559006","TX","PE - Vincent P. Rascon","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-01","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Vincent P Rascon, DPM",1346236924,"91-1559006","TX","PE - Vincent P. Rascon","Humana","Participating","Enrollment Complete","2011-01-01","1346236924","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006","TX","PE - Vincent P. Rascon","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1346236924","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006","TX","PE - Vincent P. Rascon","Cigna","Participating","Enrollment Complete","2010-08-01","1346236924","","2020-04-22","04/22/2020--S/W Rica of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 8/1/2010 under the group and TIN#. Physical location is on file. Call ref# Rica04202020.\ncopied note from spreadsheet-tisha rader"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2004-11-01","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1730181389","","2020-07-01","07/01/2020 - rec'd email confirmation from the payer that this provider is EFF - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","United Health Care","Participating","Enrollment Complete","2020-06-01","1730181389","","2020-09-01","09/01/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-27","Check Coventry portal for enrollment status, currently not enrolled. MS"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2024-03-06","Emailed contracting@careworks.com, SPNEAST@sedgwickcms.com and shedeh.hale@sedgwick.com for status. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","USA PPO","Participating","Enrollment Complete","2021-01-26","547155","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","2023-11-03","","","2023-11-20","Rcvd approval ltr. Provider effective 11/03/2023. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Sedgwick","Pending Other Enrollment","Pending Contracting","","1730181389","751997880","2024-03-06","Emailed contracting@careworks.com, SPNEAST@sedgwickcms.com and shedeh.hale@sedgwick.com for status. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Liberty Mutual","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Zurich","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Zurich","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Texas Municipal League","Participating","Enrollment Complete","2023-11-03","","","2023-11-20","Enrollment through Alliance WC. Rcvd approval ltr. Provider effective 11/03/2023. See Alliance WC payor line. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Texas Mutual","In Process","Payor Follow Up","","","","2024-03-07","Emailed wwtxcontracts@texasmutual.com for status. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2004-11-01","1730181389","","2020-07-31","7/31/2020 - Rec'd email from the payer stating \"I also show Rand attached to Permian, effective 11/1/04. \" - Stacey Hudak"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Liberty Mutual","Participating","Enrollment Complete","2002-11-15","1316965403","562697415","2020-08-21","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Humana","Participating","Enrollment Complete","2011-05-04","1316965403","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Rail Road Medicare","Participating","In House Enrollment","","","","2020-10-26","10/26/2020 - This clinic performs their own medicare enrollment in house. They have not provided me with the proper information to check the status of this RR Medicare enrollment through the portal. Moved to IN HOUSE ENROLLMENT to remove from work list - Stacey Hudak"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Galaxy Health","Participating","Enrollment Complete","2001-05-23","1316965403","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 05/23/2001 – Archie Candiasan"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Tricare Prime","Panel Closed","Panel Closed","","","","2021-07-09","7/9/2021 The payor is no longer extending contracts to new groups at this time; however, required to check on-line for future openings of the panel. KFrazier"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Cigna","Participating","Enrollment Complete","2018-11-22","","","2020-12-23",""]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Medicare","Participating","Enrollment Complete","2008-12-01","613616","613616 (provider and group in one enrollment)","2020-07-06","07/06/2020 - was able to obtain PECOS login and sign in to verify - Provider Medicare ID# 613616 EFF 12-1-2008 at service location of 2407 W Louisiana Ave - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Zurich","Participating","Enrollment Complete","2019-07-24","","","2020-09-10","9/10/2020 Confirmed provider is participating with Coventry Integrated Network under delegation with location on file. Kimberly Frazier"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","","HealthSmart PPO","Participating","Enrollment Complete","2019-10-04","10697754","","2020-07-21","07/21/2020 - Rec'd email with a spreadsheet from the payer indiciating this provider is EFF at this service location with this TIN - linked to WEST TEXAS PHYSICIANS ALLIANCE MDDO delegation - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","","Boon Chapman","Participating","Enrollment Complete","2020-04-01","1780892760","","2020-10-05","Enrollment through PHCS"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Humana","Participating","Enrollment Complete","2019-05-01","1780892760","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","","Humana","Participating","Enrollment Complete","2019-05-01","1780892760","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Amerigroup","Participating","Enrollment Complete","2020-04-15","07110928","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","","Omni PPO","Participating","Enrollment Complete","2019-05-01","1780892760","","2020-06-26",""]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Cigna","Participating","Enrollment Complete","2019-12-16","1780892760","","2020-07-20","07/20/2020 - moved to completed status after reviewing the follow up complete note - Stacey Hudak"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1093928913","","2020-10-08","10/8/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-06-30","","","2022-07-01","7/1/2022 Provider is PAR and linked to group TIN/location effective 6/30/2020.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-09-01","4341928","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this providers service location/TIN update has been completed - \"Name: Chandan Mazumber\nPID: 4341928\nEffective date: 09/01/2020\" - Stacey Hudak"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","4341928","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 4341928. KFrazier"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-09-01","","","2021-04-22","4/22/2021 Rcvd email from Kim Brechbiel <KJBrechbiel@aetna.com> that provider is particpating and linked to TIN/location effective 9/1/2020.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-09-01","4341928","","2021-07-29","7/29/2021 Submitted demographic update to Intake_pdm@cigna.com on group level requesting practice location be added for provider. KFrazier"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","9672268","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 9672268  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-05-10",""]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-09-17","","","2022-03-09","4/9/2022 Per roster received from Galaxy provider is listed as PAR and linked to group TIN/location effective 9/17/2020.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 9132703  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2020-07-23","07/23/2020 - provider maintains this enrollment in house. Not Symplr. - Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","1336304120","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2013-08-22","1336304120","","2020-06-05","06/05/2020 - Rec'd spreadsheet from the payer stating provider is EFF - Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-09-17","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 9/17/2020.   DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-12-15","1306167309","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-06-22","355008ZV0W","519061","2020-04-20","04/20/2020 - found EFF info through group PECOS to update payer lines - Stacey Hudak"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Amerigroup","In Process","Payor Follow Up","","","","2023-12-28","12/28/2023 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of delegated roster submission.   DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Humana","Participating","Enrollment Complete","2023-01-09","","","2023-08-31","8/31/2023 Per email from Marcus Wester at Humana January delegated roster has been completed and provider is PAR effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Cigna","Participating","Enrollment Complete","2023-09-19","","","2023-10-12","Contract has been signed and executed. MS"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-15","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/15/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-01-14",""]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Tricare Prime","Participating","Enrollment Complete","2023-06-02","","","2024-01-25","Confirmed via the Tricare portal, the provider is Credentialed and In Network. MS"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2024-02-01","","","2024-02-01","02/01/2024 CAQH Reattested wthompson"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2014-07-28","356720ZGML","TXB115966","2020-05-14","05/14/2020 - Rec'd welcome letter from the clinic and was able to moved to complete status - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2018-10-15","1306162557","","2020-06-29","06/29/2020 - confirmed that IMS is effective, therefore this is also participating - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","tx","PE - Permian Basin Kidney Center Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-10-02","10-2-2019","","2020-07-21","07/21/2020 - Rec'd email from the payer stating this provider is EFF with this TIN/service location under the WEST TEXAS PHYSICIANS ALLIANCE MDDO\ndelegation - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","Ambetter","In Process","Payor Follow Up","","","","2024-02-23","Requested participation status, effective date and location confirmation from SHP (email sent to shpdelegation@superiorhealthplan.com); pending response. PA."]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Multiplan","Participating","Enrollment Complete","2020-04-01","1528299872","Permian Basin Kidney Center Inc","2020-05-05","05/05/2020 - Rec'd email from the payer stating \"The MultiPlan / PHCS Network Application for Anand Reddy and Asif Ansari is complete. Network participation became effective as of 4/1/2020 with MultiPlan and PHCS. The provider’s network participation is through Permian Basin Kidney Center Inc.\" - stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","IMS","Participating","Enrollment Complete","2019-10-01","1528299872","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","IMS","Participating","Enrollment Complete","2019-10-01","1528299872","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","tx","PE - Permian Basin Kidney Center Inc","Superior","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","TriCare Standard","Participating","Enrollment Complete","2019-08-28","1528299872","","2020-09-04","09/04/2020 - Rec'd access to this TIN and was able to confirm through the payer site that this provider/service location are effective and NON Networked as of 8-28-2019 - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","TriCare Standard","Participating","Enrollment Complete","2019-08-28","1528299872","","2020-09-04","09/04/2020 - Rec'd access to this TIN and was able to confirm through the payer site that this provider/service location are effective and NON Networked as of 8-28-2019 - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Ambetter","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-04-03","","","2021-03-29","3/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective 4/3/2020.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Aetna","Participating","Enrollment Complete","2019-10-15","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2021-01-07","","","2021-03-26","3/26/2021 Rcvd confirmation email from Jamie Roberts that February delegation roster adds have been completed.  DCannon"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2017-04-14","5715174","","2020-12-30","12/30/2020 - S/W Lee of Cigna @ 800-882-4462, As per rep provider is on file and participating under the tax id effective 04/14/2017 with the provider id: 5715174, location is on file, provider is credentialed in the state of TX and enrolled independently, call ref# LeeP12/29/2020  DCannon"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-04-09","4/9/2021 Provider is listed on the HealthSmart website provider directory as participating at location.  I have requested an updated delegated roster from cgc.data@healthsmart.com.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1295109510","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 1-1-2017 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1295109510","","2020-07-27","IMS complete"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-05-26","2383552","","2021-07-22","7/22/2021 Received an email from PDMCOGZ@cigna.com confirming provider is now participating under group Tax ID effective 5/26/2021 with assigned provider ID 2383552. KFrazier"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1295109510","","2020-07-27","IMS complete"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2016-05-10","1233420","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-04-06","1295109510","West Texas Physicians Alliance","2020-09-28","09/28/2020 - Rec'd emailed spreadsheet showing this provider is EFF with these networks: Multiplan/PHCS/BeechStreet but under the delegation with: West Texas Physicians Alliance - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2016-06-01","1215254156","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2021-02-12","1215254156","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 2/12/2021.  DCannon"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2016-07-28","1215254156","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Humana","Participating","Enrollment Complete","2023-10-11","1063962355","","2024-01-24","1/24/2024 Rcvd email from Priscilla Albertine at MQA with Humana update.  Provider is PAR and linked to group TIN and both locations are on file effective 10/11/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2024-02-01","14041680","","2024-02-01","02/01/2024 CAQH Reattested wthompson"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Aetna","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete","2023-07-20","Q00602386","","2023-11-16","Confirmation of approval received. MS"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete","2023-07-01","1063962355","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete","2023-06-01","3015965","","2023-10-25","10/25/2023 Called First Health at 800-226-5116 spoke w/ Leandra provider is PAR and linked to group TIN and both locations effective 6/1/2023.  PID 3015965.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Participating","Enrollment Complete","2023-10-16","","","2024-01-26","Received confirmation for 19th St. location eff 10/16/2023. MS"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","1063962355","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from June has been completed and provider is PAR effective 7/20/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2023-10-16","","","2024-02-13","Provider has been linked to 19th St. location eff 10/16/2023. MS"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2023-10-16","","","2024-02-13","Provider has been linked to 19th St. location eff 10/16/2023. MS"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-06-07",""]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2023-07-01","1063962355","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","HealthSmart PPO","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2019-08-30","1467745240","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Also rec'd email confirmation from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2015-05-12","1467745240","752656723","2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2014-12-29","383114YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2014-12-29","383114YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-08-28","1467745240","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 2-20-2020 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-15",""]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2023-02-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 2/1/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2016-07-13","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/13/2016.  DCannon"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2015-10-01","2785559","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2015 PID # --tisha rader"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2015-10-01","2785559","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2015 PID # --tisha rader"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-08-10","1770883191","","2020-06-05","06/05/2020 - rec'd email from the payer stating provider is EFF - stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2015-10-26","1770883191","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2020-01-01","1770883191","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2015-05-11","415412YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2018-04-01","P02124304","","2020-03-25","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 04/01/2018 with provider number P02124304. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1275044422","","2020-07-27","IMS complete"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-09-01","1275044422","","2020-09-14","09/14/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Sep 9, 2020 9:21:18 AM. Your request was assigned reference number PR-5483455 .\" - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-25","14243053","","2024-01-25","01/25/2024 CAQH Reattested wthompson"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2018-07-24","1275044422","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- ---roster also shows effective date: 1/1/20--Tisha Rader"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1275044422","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-01","","","2021-12-14","12/14/2021 Provider linked to location per portal as of 12/1/2021. Cbankston"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1013990761","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2015-12-08","1013990761","","2020-06-30","6/30/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-01","","","2021-12-14","12/14/2021 Provider linked to location per portal as of 12/1/21. Cbankston"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2017-07-26","2125916","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-07-22","6653474","","2020-07-24","7/24/2020 - Rec'd email from the payer stating \"Your effective date is 07/22/2020. Your provider identification number is 6653474\" - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-10-03","","","2022-02-24","2/24/2022 Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and participating effective 10/03/2017 under the group and TIN#. Provider ID#  12418437. Physical location is on file. Call ref# 7919804 -DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-01","","","2024-01-30","1/30/2024 Rcvd email confirmation from UHC that January delegated roster has been completed.  Provider is PAR and linked to group/location effective 2/1/2024.  MPIN # 001163117.   DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Re-Credentialing","2021-04-01","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-13","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Jen Videan"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","","Multiplan","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-07-01","","","2022-11-01","11/1/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Re-Credentialing","2023-10-02","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Re-Credentialing","2023-05-01","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-05-06","8228233","","2021-05-07","5/7/2021 Received email from discovercigna@information.cigna.com confirming provider has been approved effective 5/6/2021 with assigned provider ID number 8228233. KFrazier"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for details. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-05-01","","","2023-09-27","9/27/2023 Per email response from Marcus Wester at Humana May delegated roster has bee completed.  Provider is PAR and linked to group/location effective 5/1/2023.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","In Process","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Re-Credentialing","","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-04-06","","","2021-06-04","6/4/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective 4/6/2021.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-14","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/14/2023.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Add Info Submitted","","","","2024-01-30","1/30/2024  Emailed UHC Medical Group Roster Update form to hpdemo@uhc.com to add provider to location.  Reference # PR-8014097. DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Re-Credentialing","2022-07-01","5951375","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","","","2023-09-08","Confirmed enrollment with all locations under WesTex. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Add Info Submitted","","","","2024-01-30","1/30/2024  Emailed UHC Medical Group Roster Update form to hpdemo@uhc.com to add provider to location. Reference # PR-8014097.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-07-01","","","2023-11-20","11/20/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/1/2022.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-10-02","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-26","Confirmed provider is linked to Briarwood location effective 9/20/23. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location confirmed eff 10/9/23. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Re-Credentialing","2023-05-01","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-05-23","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 5/23/2021.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2021-03-25","1163117","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 3/25/2021 and assigned provider ID 1163117. KFrazier"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Gallagher","Participating","Enrollment Complete","2014-07-01","1112323","","2020-08-17","Provider is particpating with WC Network effective 7/1/2014, which is under the Aetna delegation. Kim Frazier"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Liberty Mutual","Participating","Enrollment Complete","2018-10-01","","","2021-01-25","1/25/2021 - Rcvd email from payer confirming participating under tax ID and at location effectice 10/1/2018.  DCannon"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2018-11-14","","","2024-01-26","Confirmed Provider is credentialed  and in network with Tricare. MS"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-10-29","1437175163","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 10-29-2018. Provider is networked with Beechstreet. - Stacey Hudak"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","United Health Care","Participating","Enrollment Complete","2015-12-14","2748091","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","IMS","Participating","Enrollment Complete","2010-02-01","1134151756","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","TX","","United Health Care","Participating","Enrollment Complete","2015-10-26","1184727562","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Boon Chapman","Participating","Enrollment Complete","2014-06-04","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 6/4/2014.  DCannon"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","IMS","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","TX","","IMS","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 4/3/2020.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Priscilla Albertine at MQA sent 2nd follow-up email to Marcus Wester at Humana to try and get an update on WTUC address provider load for all providers.  DCannon"]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2021-12-01","","","2021-12-07","12/7/2021 Rcvd email from SuperiorDelegation that November delegation roster has been completed and providers are loaded under appropriate group TIN/locations effective 12/1/2021.  DCannon"]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2008-11-10","8L9009","0008AH","2020-05-26","05/26/2020 - Signed onto Novitas application checker and used tracking# to find that this reval was approved - Stacey Hudak"]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-09-01","9560591","","2021-09-03","9/3/2021 Received an email from pdmcogz@cigna.com confirming provider is participating under group Tax ID effective 9/1/2021 with assigned provider ID number 9560591. KFrazier"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Re-Credentialing","2023-09-06","002854139","","2024-02-19","2/19/2024 - submitted recred status via delegated monthly roster on 02/15/2024. PA."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-06","002854139","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/6/2023.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2015-08-28","1437356730","","2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-12","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-26","Confirmation received  the provider is linked to Briarwood location effective 9/20/23. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2008-04-02","190610903","079837301","2020-03-11","03/11/2020 - Was able to confirm this rpovider is EFF through payer portal/Group TMHP enrollment. The provider is affiliated with the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West  - Stacey Hudak"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-18","Received confirmation of enrollment. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-02","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-12-01","","","2021-12-14","12/14/2021 Per portal, provider linked to location as of 12/1/2021. Cbankston"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-10","","","2023-10-09","10/9/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/10/2023.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Re-Credentialing","2023-09-06","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Re-Credentialing","2023-09-06","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-06","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/6/2023.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Re-Credentialing","2023-09-06","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 4/3/2020.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 12/1/2018.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 12/1/2018.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Re-Credentialing","","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-03-07","Application to add this location to the Medicare record has been submitted and is still processing. MS"]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","002854139","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider complete. MPIN 002854139. Cbankston"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-08-01","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 08/01/2023. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Superior","Participating","Enrollment Complete","2019-03-01","1437356730","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF with this TIN under PRIMED DELEGATED agreement - Stacey Hudak"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Re-Credentialing","","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-02-01","12235261","","2024-02-01","02/01/2024 CAQH Reattested wthompson"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Re-Credentialing","2023-09-06","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Re-Credentialing","2023-09-06","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Re-Credentialing","2020-04-15","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2010-09-30","1912068446","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1087929","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-12-01","","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is participating under group Tax ID effective 12/1/2020 and assigned PIN number 9631791. Kimberly Frazier"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2020-12-01","","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is participating under group Tax ID effective 12/1/2020 and assigned PIN number 9631791. Kimberly Frazier"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-20","1760501720","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1760501720","","2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2014-11-04","1760501720","","2020-09-21","09/21/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2008-01-01","8K8025","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2008-05-13","1760501720","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2008-11-01","P00716501","","","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2008 with provider number P00716501. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2012-03-01","01448885","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- additional effective dates listed on roster are:  1/1/17, 11/1/16, 8/1/12, & 1/1/2020--Tisha Rader"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1093937948","","2020-08-21",""]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2010-04-16","1093937948","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1093937948","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2009-03-24","8L6420","0008AH","2020-03-13","03/13/2020 - Clinic forwarded Medicaid TMHP approval letter showing where the provider was linked to the group - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2020-02-26","6493392","","2021-11-15","11/15/2021 Per f/u note S/W Steven of Cigna @ 800-882-4462. NPI# for the provider is on file  shows LINKED and  Par under the group and TIN#,  effective 2/26/2020 , the physical location is on file and the Provider ID is 6493392.   DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2008-11-01","P00716501","","2020-03-30","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2008 with provider number P00716501. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2015-04-29","1093937948","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Liberty Mutual","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Aetna","Participating","Enrollment Complete","2019-01-01","1376723361","","2020-04-15","04/15/2020 - Rec'd email from the follow up team stating \"S/W Ron of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 1/1/2019. Physical Location is on file. Provider ID #9469407. Call ref # 5226062453\"\nIt's clearly stated that THIS PROVIDER HAS DIRECT CONTRACT - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2014-12-01","2681483","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 12/1/2014.  PID #2681483  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-12-19",""]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","USA PPO","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  \nDCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","HealthSmart PPO","Participating","Enrollment Complete","2016-04-25","13512484","","2020-07-21","07/21/2020 - rec'd spreadsheet from the payer stating this provider/TIN/service location is EFF - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Caprock (CapStar)","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2014-11-28","1376723361","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2019-10-01","9469407","","2023-09-05","9/5/2023 Per email from Priscilla Albertine at MQA she received a roster confirming that provider is PAR and linked to group TIN/location effective 10/1/2019.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2020-01-30","1376723361","","2020-06-25","06/25/2020 - Verified this provider is participating with this group through payer portal. This group is NON NETWORKED, but this provider is certified - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 1/1/2022.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 1/1/2022.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 1/1/2022.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-08-22","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/22/2020.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-18","Received confirmation of enrollment. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-01-03","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 1/3/2022.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-26","","","2024-03-06","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/26/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-26","","","2024-03-06","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/26/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location confirmed eff 10/9/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location confirmed eff 10/9/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-01","13780299","","2024-02-01","02/01/2024 CAQH Reattested wthompson"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-01","13780299","","2024-02-01","02/01/2024 CAQH Reattested wthompson"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-02-01","13780299","","2024-02-01","02/01/2024 CAQH Reattested wthompson"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Liberty Mutual","Delegated - Third Party","Add to Next Delegated Roster","2018-02-04","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","Amerigroup","In Process","Payor Follow Up","","","","2023-12-28","12/28/2023 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of delegated roster submission.   DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not showing on the Coventry portal. Please add to next delegated roster submission. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2017-09-01","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2017-09-01","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2017-09-06","P01938882","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Add to Next Delegated Roster","2015-12-01","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-08-22","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/22/2020.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Gallagher","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-01","9/1/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Confirm Par Status","","","","2024-02-06","2/6/2024 - sent email to cvtyrostercollection@verisys.com requesting participation status and location confirmations, case# 16409594. PA"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2014-12-01","1376723361","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-19","9469407","","2023-10-19","10.16.2023 S/W Chris of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective on 06/19/2023. No next recredentialing date available. PIN: 9469407. Servicing location is on file. Payer# 60054. Call ref# 6166862305. - Willie Ravas"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2014-11-28","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-03-09","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 3/9/2017.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-03-09","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 3/9/2017.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","IMS","Participating","Enrollment Complete","2019-09-01","1376723361","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","IMS","Participating","Enrollment Complete","2019-09-01","1376723361","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Per Healthsmart provider portal provider is still not loaded under group TIN.  Provider still not updated will allow more time, check back in 2 weeks.   DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2017-11-28","1376723361","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2016-05-18","1376723361","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 03/27/2020 Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 03/27/2020 Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Galaxy Health","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Rail Road Medicare","Participating","Enrollment Complete","2017-09-06","P01938882","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 8867748 DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 8867748 DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2014-12-01","2681483","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 12/1/2014 PID # 2681483\ntisha rader"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","Multiplan","Participating","Enrollment Complete","2023-10-02","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Cigna","Participating","Enrollment Complete","2010-11-18","1790972610","","2020-04-22","04/22/2020--S/W Rica of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 11/18/2010 under the group and TIN#. Physical location is on file. Call ref# Rica04202020.\ncopied note from spreadsheet-tisha rader"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1790972610","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2017-09-22","1447415476","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 9-22-2017 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-01-25","1447415476","","2020-04-30","04/30/2020 - confirmed through payer portal that this provider is EFF and linked to TIN/Service location - Stacey Hudak"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2017-07-10","468835ZV0W","519061","2020-02-19","02/19/2020 - Signed into PECOS and confirmed that this provider is EFF with Medicare group PTAN 519061  as of 7-10-2017 - Stacey Hudak"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2012-07-01","1225182314","","2020-04-22","04/22/2020--SW Monic of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 7/1/2012. Location is on file. Call ref# Monic4202020.\n-copied note from spreadsheet-tisha rader"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2011-03-01","1225182314","","2020-07-15","07/15/2020 - Rec'd email through Humana Secure Mailbox stating \"i have attached a small roster with providers still active under that tin but also not on your roster.\"  I confirmed that this provider does remain effective with our group - Stacey Hudak"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Humana","Participating","Enrollment Complete","2013-08-29","1194813709","","2020-06-30","6/30/2020 - Rec'd email spreasheet from payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/1/2020.   DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2019-01-01","8553905","","2020-02-27","02/27/2020 - Rec'd email response from the payer stating that this provider is EFF 1-1-2019 with Premier Family under PID# 8553905 - Stacey Hudak"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2017-11-29","1619982584","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2017-10-31","00003110523","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 10/31/2017.   MPIN# 00003110523.   DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location and providers specialty is listed as Hospice/Palliative Care effective 5/1/2023.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-08-01","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","","United Health Care","Participating","Enrollment Complete","2017-10-31","3110523","","2020-07-28","7/28/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2017-10-31","3110523","","2020-07-28","7-28-2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-09-14","","","2023-11-20","11/20/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/14/2023.  DCannon"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","","First Health Coventry","Participating","Enrollment Complete","2020-08-01","","","2021-10-13","10/13/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 8/1/2020.  DCannon"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-08-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/1/2023.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2023-09-01","","","2024-01-25","1/25/2024 Rcvd confirmation from Superior that provider is PAR and linked to group TIN/location effective 9/1/2023.  DCannon"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2022-09-29","","","2023-10-11","Welcome letter rcvd from TMHP. Effective 09/29/2022 at 400 Rosalind Redfern Grover Pkwy Ste 200 Midland TX. Jen Videan"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-07","This location is not Tricare Credentialed, and the panel is closed for new enrollments. MS"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-02-13","","","2024-02-29","Provider has been linked to this location. MS"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Provider Type Not Enrolled","Application Resubmitted","","","","2024-03-04","03/04/2024 - submitted PACT to shpdelegation@superiorhealthplan.com for the inclusion of provider in the Behavioral Lines of Business. PA"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-01-01","","","2024-01-18","Per TMHP application closed and provider is enrolled effective 01/01/2024. Still waiting on welcome letter. Jen Videan"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","DO NOT ENROLL","In House Enrollment","2023-11-22","","","2024-02-06",""]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-04","Pending Aetna Approval. MS"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2011-09-10","1376556019","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-10-2011 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2011-09-06","P01465345","","2020-03-25","3/25/2020--\"\n3/25/2020-Per online check, provider is now PAR effective 09/06/2011 with provider number P01465345. Attached welcome letter to payor line.-Elonah Grace B.Gelig \""]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-05-05","1376556019","West Texas Physicians Alliance","2020-09-28","09/28/2020 - Rec'd roster stating this provider is linked to West Texas Physicians Alliance\n as of 5-10-2016. Provider is networked with Multiplan/PHCS/BeechStreet  - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2011-09-01","1376556019","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-02-13","1376556019","","2024-02-29","Provider is linked to this location. MS"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2020-07-20","1558392779","","2020-09-24","09/24/2020 - moved to a completed status after reviewing follow up complete note - Stacey Hudak"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30","1558392779","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-10-01","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 10/1/2020.  DCannon"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2020-07-20","","","2020-08-25","Confirmed provider is participating under delegation effective 7/20/2020. Kimberly Frazier"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2010-06-06","3015766","","2020-06-08","06/08/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-03-04","","","2020-07-21","07/21/2020 - rec'd email with a spreadsheet showing this provider/TIN/service location are PAR with this payer under WEST TEXAS PHYSICIANS ALLIANCE Delegated - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-08-01","1174846364","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-12-01","","","2023-12-01","12/1/2023 Updated and uploaded current malpractice COI and re-attested.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Humana","Participating","Enrollment Complete","2017-05-01","1881711778","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2021-08-02","1881711778","","2021-10-06","10/6/2021 Rcvd email from CapRock that monthly delegated roster has been loaded and the provider is PAR and linked to group TIN/location effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete","2010-08-01","1945548","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2010 PID # 1945548-tisha rader"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Aetna","Participating","Enrollment Complete","2021-08-02","9826163","","2021-10-29","10/29/2021 Per email from Mary Hanna at Aetna provider is PAR and linked to group TIN and location effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Galaxy Health","Participating","Enrollment Complete","2021-08-02","1881711778","","2021-10-06","10/6/2021 Rcvd email from Karen Avalos at Galaxy confirming that the August delegated roser provider load has been completed and providers are loaded under TIN/locations effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete","2022-09-01","1881711778","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","USA PPO","Participating","Enrollment Complete","2021-01-26","1142937","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete","2010-07-25","P01233942","","2022-02-10","2/10/2022 Per RR Medicare portal provider is PAR effective 7/25/2010.  PTAN # P01233942  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Medicare","Participating","Enrollment Complete","2010-07-25","TXB111410","00608K","2020-05-04","05/04/2020 - was able to find/confirm PTAN through PECOS login - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1881711778","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","387297379","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","387297379","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete","2022-09-01","1881711778","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Rail Road Medicare","Participating","Enrollment Complete","2010-07-25","P01233942","CF8499","2020-05-04","05/04/2020 - Was able to confirm this provider is EFF through payer portal - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Medicaid","Participating","Enrollment Complete","2010-07-25","1881711778","","2023-12-14","Michael Wolbert NPI is a performing provider of the group for any location of the group. Jen Videan"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2014-08-08","1124350442","","2020-04-16","04/16/2020 - Rec'd email from the payer with a spreadsheet confirming this provider is effective with ALL PRODUCTS under a PRIMED DELEGATED contract - Stacey Hudak\n\n**verified with payer that the provider is networked with: \nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-25","12038216","","2024-01-25","01/25/2024 CAQH Reattested wthompson"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1487837712","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-04-01","2122957","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 4/1/2020 PID # 2122957\ntisha rader"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2016-07-08","1437402278","","2020-06-25",""]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2016-07-01","2876013","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 7/1/2016 PID # 2876013"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-12-29","12/29/2022 Rcvd email from Superior Delegation that August delegation roster has been completed and providers are loaded under appropriate group TIN/locations effective 9/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-11-15","","","2022-03-11","3/11/2022 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 11/15/2021.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-07-08","1437402278","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-01-03","13489266","","2022-02-24","2/24/2022 Per follow-up note from 2/18/2022 -  NPI# for the provider is on file, shows linked and Par under the group and TIN# effective 11/15/2021, the physical location is on file and the Provider ID is 13489266.  Case ref#7920144. - DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2017-04-19","003639846","","2022-04-18","Received email networkhelp@uhc.com, Matthew Sanchez is effective with the group contract 4/19/17. Cbankston"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2022-12-01","Q00375443","CE1588","2022-11-30","11/30/2022 Rcvd RR Medicare approval letter.  PTAN # Q00375443 - effective 12/1/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-10-10","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-10-10","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-10-10","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 10/10/2022.   DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-10-10","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2023-02-01","7016986","","2023-02-01","02.01.2023 S/W Erika of Aetna @ 800-353-1232. Per rep, provider is showing participating with an Effective date 02/01/2023 and link under the Group and TIN. Provider ID 7016986, Payer ID 60054 and Recredentialing date 02/01/2025. Service location is on file. Call ref# 6131400691. -Danico Gabriel Melendres"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-10-10","","","2022-12-29","12/29/2022 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 10/10/2022.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-04","8/4/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 6/1/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","United Health Care","Participating","Enrollment Complete","2021-09-03","","","2021-08-20","8/19/2021 Received group executed group agreement confirming participation for Dr. Caglia, which is effective 9/3/2021, which was forwarded to Rebecca Pontaski for distribution to the appropriate staff.  KFrazier"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-10-12","1619008141","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 10-12-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2016-10-05","1619008141","","2020-02-12","2/12/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n03/20/2020 - Rec'd confirmation from Multiplan/Texas True Choice is EFF for this provider/service location. - stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-10-12","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 10/12/2016.  DCannon"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-01-25","11857339","","2024-01-25","01/25/2024 CAQH Reattested wthompson"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1093935975","","",""]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2021-12-31","","","2022-02-25","2/25/2022 Per Tricare portal, provider is linked to location eff 12/31/2021. Cbankston"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2021-12-31","","","2022-02-25","2/25/2022 Per Tricare portal, provider is linked to location eff 12/31/2021. Cbankston"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","12802966","","2022-05-19","5/19/2022 Per roster received from Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  PID #  12802966.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-10","","","2022-04-05","4/5/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-10","","","2022-06-19","6/19/2022 Per email received from V. Thomas at Humana provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-10","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/1/2020.   DCannon"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1871782961","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-10-01","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 10/1/2020.  DCannon"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1053601344","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019 - Jesriel Segovia"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-04-04","1053601344","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","IMS","Participating","Enrollment Complete","2018-02-28","1972816189","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Amerigroup","Participating","Enrollment Complete","2019-07-30","1972816189","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","USA PPO","Participating","Enrollment Complete","2018-08-29","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2019-10-01","1972816189","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Cigna","Participating","Enrollment Complete","2019-06-04","1972816189","","2020-08-26","08/26/2020 - moved to completed status after reviewing followup complete note - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2018-01-30","","","2021-08-06",""]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2017-09-01","1972816189","","2020-03-10","03/10/2020 - Signed onto payer portal and found this provider is linked to the group at this service location. Please note that this TIN is OUT OF NETWORK and the payer is not currently accepting new in network groups at this time. Due to this, credentialing is not required - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2018-09-01","1427452945","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2018-08-01","2878466","","2020-03-20","03/20/2020 - Rec'd from the payer stating this provider is EFF under PID# 2878466 - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","1427452945","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Medicine PA","CAQH","Participating","CAQH Reattested","2024-01-30","","","2024-01-30","01/30/2024 CAQH Reattested updated and uploaded license wthompson"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-30","","","2024-01-30","01/30/2024 CAQH Reattested updated and uploaded license wthompson"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1760860720","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-09","","","2023-11-03","11/3/2023 Per email received from Scott & White provider is PAR and linked to group effective 11/9/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-11-01","6107649","","2023-11-29","11.29.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 11/01/2023. Next recredentialing date is on 11/01/2026. PIN: 6107649. Servicing location is on file. Payer# 60054. Call ref# 6172179371. - Willie Ravas"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-07-24","1760860720","","2020-06-26",""]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-11-01","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-01","0040519489","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 11/1/2023.  MPIN# 0040519489.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-08-01","P02179382","DW7662","2020-05-04","05/04/2020 -verified and moved to completed status - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","HealthSmart PPO","Participating","Enrollment Complete","2022-06-01","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Wellcare","Participating","Enrollment Complete","2022-06-01","","","2022-07-01","7/1/2022 Received June Monthly Validation roster from Superior and provider is PAR and linked effective 6/1/2022.  DCannon"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2016-08-02","1255614970","364596201","2023-09-06","Downloaded Approval letter from TMHP. Effective 08/02/2016. Jen Videan"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1255614970","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2017-01-10","1255614970","","2020-03-20","03/20/2020 - Rec'd email from the payer (multiplan/true texas choice) stating this provider/service location is EFF with amerigroup - Stacey Hudak"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","","Cigna","Participating","Terminated","2016-12-20","6703681","","2021-05-24","5/24/2021 Provider was loaded under delegation with WTPA; however, client terminated relationship and provider was termed effective 3/31/2021. Confirmed provider is not currently credentialed outside of delegation and requires full credentialing. Kfrazier"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-08-21","","","2021-04-07","4/7/2021 Rcvd roster from Mary Rodriguez 4/5/2021 listing provider as participating.  DCannon"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2020-06-09","1447412895","","2020-09-09","09/09/2020 - moved to completed status after reviewing previous note - Stacey Hudak"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-10-18","319012ZV0W","519061","2020-04-27","04/27/2020 - Confirmed EFF information through Group PECOS enrollment - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Rail Road Medicare","Participating","Enrollment Complete","2016-01-09"," P01708900","DW5495","2020-05-04","05/04/2020 - confirmed EFF info through payer portal - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","TriCare Standard","Participating","Enrollment Complete","2024-01-19","","","2024-02-07","Confirmed provider is enrolled at this location. MS"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","Cigna","Participating","Enrollment Complete","2019-09-01","8628903","","2020-07-16","7/16/2020 - Rec'd email from the payer stating \"Thank you for your submission. This is to confirm that your request has been completed.\" - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Per Healthsmart provider portal provider is still not loaded under group TIN.  Provider still not updated will allow more time, check back in 2 weeks.   DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","Multiplan","In Process","Application Submitted","","","","2024-01-12","1/12/2024 Delegated roster submitted.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Aetna","Participating","Enrollment Complete","2019-09-01","1447406137","","2020-09-22","09/22/2020 - Rec'd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","Aetna","Participating","Enrollment Complete","2019-09-01","1447406137","","2020-09-22","09/22/2020 - Rec'd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-30","1/30/2024 Per UHC portal provider load in Wellmed is still pending.  Will check back in a few days.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","Rail Road Medicare","Participating","Enrollment Complete","2016-01-09","P01708900","DW5495","2024-03-06","Provider is enrolled. MS"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","Amerigroup","Participating","Enrollment Complete","2018-05-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/3/2018.  DCannon"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending UHC enrollment.  DCannon"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending UHC enrollment.  DCannon"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-02-06","","","2024-02-05","2/05/2024 - received an email confirmation provider is PAR, eff. 2/06/2024. Provider is PAR with the following networks: \nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO.  -PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-02-06","","","2024-02-05","2/05/2024 - received an email confirmation provider is PAR, eff. 2/06/2024. Provider is PAR with the following networks: \nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO.  -PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-02-20","2/20/2024 Submitted application via delegated roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-01","","","2024-03-08","Rcvd approval letter. Provider effective 03/01/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-01-18","WTUC has an ancillary contract where midlevel services are billed under the group contract. Individual enrollment isn't required. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending Superior enrollment.  DCannon"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-05","","","2024-03-05","03/05/2024 CAQH Reattested Updated and uploaded COI"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-03-05","","","2024-03-05","03/05/2024 CAQH Reattested Updated and uploaded COI"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2024-03-05","Emailed SPNEAST@sedgwickcms.com for status. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024 for First Health. FC."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024 for First Health. FC."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-02-01","6H8501","","2024-01-31","Received approval letter eff 2/1/2024. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-02-01","Q00681843","DX4335","2024-03-06","Provider is linked. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-02-01","Q00681843","DX4335","2024-03-06","Provider is linked. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-03-12","Request submitted 01/22/2024. Allow 180 days for processing. Allow more time. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-02-20","2/20/2024 Pending Multiplan enrollment. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-02-20","2/20/2024 Pending Multiplan enrollment. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Rail Road Medicare","Participating","Enrollment Complete","2014-06-10","P02417404","DO2096","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note and downloading EFF letter - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","IMS","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","USA PPO","Participating","Enrollment Complete","2021-01-26","1312309","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records immediately upon receipt. KFrazier"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Cigna","Participating","Enrollment Complete","2020-09-15","5009460","","2020-09-18","09/18/2020 - Your effective date is 09/15/2020. Your provider identification number is 5009460.  - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2020-04-03","","","2022-02-26","2/26/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/3/2020.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Medicare","Participating","Enrollment Complete","2014-06-10","363200ZH9T","00Y323","2020-03-10","03/10/2020 - Confimed through PECOS that this provider is linked to the corect group and EFF 6-10-2014 - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","United Health Care","Participating","Enrollment Complete","2019-12-01","1750794749","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Omni PPO","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","IMS completed"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","CAQH","Participating","CAQH Reattested","2024-01-30","12740460","","2024-01-30","01/30/2024 CAQH Reattested updated and uploaded license wthompson"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete","2020-08-01","3524170","","2022-04-05","4/5/2022  Per First Health online provider directory provider is PAR and linked to group/locations  effective 8/1/2020.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1216979","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2021-09-28","","","2021-12-14","12/14/2021 Update from note made on 10/29/2021. Provider certified as of 9/28/2021. Cbankston"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1710180666","","2020-07-27","IMS complete"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-05-15","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/15/2020.   DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-05-15","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/15/2020.   DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-05-15","1710180666","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1710180666","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-01-25","11714128","","2024-01-25","01/25/2024 CAQH Reattested wthompson"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-05-01","1447406137","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-08-24","372879ZV0W","519061","2020-04-20","04/20/2020 - Group PECOS enrollment confirrmed this group is listed as provider employer - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-12-01","2550759","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/1/2020.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13",""]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-09-15","1710180666","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-08-24","P01732063","DW7662","2020-10-09","10/9/2020 - Was able to confirm RR Medicare enrollment thorugh payer site - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2017-02-06","1710180666","","2020-08-31","08/31/2020 -moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1710180666","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","341080503","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is linked to group TPI 364596201 and this provider is affiliated with the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1710180666","","2020-07-02","7/2/2020 - Received email spreadsheet from the payor confirming that this provider is EFF ath this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2016-12-16","1710180666","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-09-15","1710180666","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 9-15-2016 at this service location under a DELEGATED ENTITY - but the payer couldnt identify who - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1710180666","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-12-15","1710180666","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicare enrollment completed in-house by MCHS.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-06-30","","","2022-06-01","6/1/2022 Provider is PAR w/ Multiplan effective 6/20/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-06-30","13484074","","2022-02-24","2/24/2022 Per follow-up note on 2/17/2022 -  Provider NPI# is on file for the provider and is participating effective 6/30/2020 under the group and TIN#. Provider ID 13484074. Physical location is on file. Call ref# 7917950.  - DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2020-06-30","","","2022-10-20","10/20/2022 Rcvd email from Priscilla Albertine at MQA with roster from Marcie Eckhart-Havens at Multiplan with confirmation that provider is PAR w/ Molina under group TIN/location effective 6/30/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-11-01","","","2020-09-14",""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-11-01","","","2020-09-14",""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2020-06-30","","","2022-10-20","10/20/2022 Rcvd email from Priscilla Albertine at MQA with roster from Marcie Eckhart-Havens at Multiplan with confirmation that provider is PAR w/ Molina under group TIN/location effective 6/30/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 07/18/2019.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 06/01/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-01-13","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 1/13/2020.   DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2021-02-13","5733523","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 2/13/2021 and assigned provider ID 5733523. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","5435845","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 5435845  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2019-09-01","7132451","","2020-08-04","8/4/2020 - moved to the completed status after getting an email from the payer stating this demo update has been completed - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-03-01","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 3/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","7132451","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 7132451. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider has been added to the delegation at this TIN/service location - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-06-30","1348074","","2022-02-24","2/24/2022 Per follow-up note on 2/17/2022 - Provider NPI# is on file for the provider and is participating effective 6/30/2020 under the group and TIN#. Provider ID 13484074. Physical location is on file. Call ref# 7917950.  - DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-24","09/24/2020 - moved to completed status - PRIMED DELEGATION - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-01-13","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 1/13/2020.   DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-02-12","","","2022-06-01","6/1/2022 Per Galaxy Health provider is PAR and linked to group TIN/location effective 2/12/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-11-15","5435845","7496529","2020-11-24","11/24/2020 - Per F/U report provider is linked and participating in Network effective 11/15/2015 under the group and TIN#. Provider ID 5435845. Group ID 7496529.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-14","","","2022-02-11","2/11/2022 Per Tricare portal, provider is linked to location as of 12.14.2021. Cbankston"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-11-15","5435845","7496529","2020-11-24","11/24/2020 - Per F/U report provider is linked and participating in Network effective 11/15/2015 under the group and TIN#. Provider ID 5435845. Group ID 7496529.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","Participating","Enrollment Complete","2020-09-01","349777802","165581301","2020-10-01","10/01/2020 - Rec'd emailed confirmation of enrollment from the clinic - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2021-02-13","5733523","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 2/13/2021 and assigned provider ID 5733523. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider has been added to the delegation at this TIN/service location - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 06/01/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","5435845","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 5435845  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-02-12","","","2022-06-01","6/1/2022 Per Galaxy Health provider is PAR and linked to group TIN/location effective 2/12/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","Enrollment Complete","2020-09-01","1F3577","00304W","2020-10-14","10/14/2020 - Rec'd requested payer welcome letter from the clinic to update this payer line - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 07/18/2019.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicare enrollment completed in-house by MCHS.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2020-09-29","","","2020-10-23","10/23/2020 Upon review of the self-service portal provider is certified as a non-network provider under Group Tax ID and location is confirmed, effective 9/29/2020. Kimberly Frazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2016-09-16","03421665","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 9/16/2016;  PLUS - eff 9/16/2016, Star_Kids - eff 10/22/2015.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2019-09-01","7132451","","2020-08-04","8/4/2020 - rec'd email from the payer stating that this demo update has been completed.\" - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","Enrollment Complete","2020-09-01","1F3577","00304W","2020-10-14","10/14/2020 - Rec'd requested payer welcome letter from the clinic to update this payer line - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-14","","","2022-02-11","2/10/2022 Per Tricare portal, provider is linked to location as of 12.14.2021. Cbankston"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","7132451","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 7132451. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04",""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicaid enrollment completed in-house by MCHS.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-08-07","1659728855","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 8-7-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-06-14","1659728855","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-06-16","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","396567501","079837301","2020-01-29","01/29/2020 - Provider is linked to group. Provider is only PAR with traditional medicaid - stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-08-01","1659728855","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 8-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12","13681723","","2020-07-21","07/21/2020 - rec'd spreadsheet from the payer stating this provider is EFF with this TIN/service location as of 6-12-2019 under the WEST TEXAS PHYSICIANS ALLIANCE MDDO delegation - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-02-02","","","2024-02-12","Rcvd revalidation approval ltr. Provider effective 02/02/2023. Jen Videan"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-05-29","7093824","","2020-07-30",""]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-10-21","1659728855","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/19/2020 - rec'd email from the payer (Multiplan/Texas True Choice) confirming that this EFF info is true - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-08-07","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 8/7/2019.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-06-01","3278559","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR  6/1/2019 PID # 3278559\ntisha rader"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1659728855","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-25","14428752","","2024-01-25","01/25/2024 CAQH Reattested wthompson"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-31","1659728855","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-01-08","","","2021-03-31","3/31/2021 Confirmed provider certified at location via Humana-Military portal effective 1/8/2021.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-09-20","1659728855","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-20-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12","1659728855","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-06-14","1659728855","","2020-06-25",""]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-01-08","","","2024-01-25","During the Tricare audit, it was found this provider is credentialed and is in network with Tricare. MS"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12","1659728855","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-04-01","786679","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2021-01-07","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 1/7/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2017-07-09","378408401","364596201","2020-12-31","12/31/2020 Confirmed provider is participating under group with assigned TPI 378408401, effective 7/9/2017. Next revalidation due 1/16/2023. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-03-01","3/1/2021 Rcvd confirmation that provider is participating with Healthsmart PPO effective 1/7/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-02-03","2/3/2021 - Rcvd confirmation email from payor stating that provider is participating and linked at location and TIN effective 1/7/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-11-01","003488587","","2021-05-12","5/12/2021 Recevied an email from United_Healthcare_Provider_Operations@uhc.com confirming provider has been loaded under group Tax ID and is now participating effective 11/1/2020 under PR-5736425 with assigned MPIN 003488587. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2020-11-01","0843337","","2021-02-26","2/26/2021 Received internal email of approval with an effective date of 11/1/2020 and assigned PID 0843337. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2021-02-01","","","2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2021-01-07","9896886","","2021-04-18","4/18/2021 Rcvd complete roster from Jamie Roberts <robertsj6@aetna.com> at Aetna listing provider as participating at TIN and locations.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","2023-01-18","01.18.2023: S/W Teresita of First Health @800-226-5116. Per rep, provider is participating, in network and linked under the group and TIN effective 12/01/2022. Provider ID# 2438435. Physical location is on file. Don't have payer#. Call Ref# 516478. - Mary Rose Acebedo"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2017-07-09","590902ZV0W","519061","2020-12-31","12/31/2020 Confirmed provider is participating under group with assigned PTAN 590902ZV0W effective 7/9/2017. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2019-08-09","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-07","1297078","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2021-01-07","","","2021-02-02","2/2/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2017-07-07","P01936022","DW7662","2020-12-31","12/31/2020 Confirmed provider is participating under group with RR PTAN P01936022, effective 7/7/2017. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-01-07","","","2021-02-02","2/2/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2017-08-01","","","2020-12-31","12/31/2020 Confirmed via self-service portal, provider is certified as non-network under group effective 08/01/2017. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 1/7/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-03-24","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 03/24/2020.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-01-26","","","2024-01-26","1/26/2024 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2024-01-26","","","2024-01-26","1/26/2024 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2024-01-26","","","2024-01-26","1/26/2024 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2022-04-11","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2022-04-11","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2016-09-22","1265872592","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 09/22/2016 under the group and TIN#. Provider is delegated to  PE - Midland Inpatient Medical Association. Physical location is on file. Call ref# 5309657469. - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1265872592","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","In Process","Application Submitted","","","","2024-03-12","Application submitted via TMHP. Request ID:20441497. Your application has been submitted and is now under review. Your request number is: 20441497\nJen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","In Process","Application Submitted","","","","2024-03-12","Application submitted via TMHP. Request ID:20441497. Your application has been submitted and is now under review. Your request number is: 20441497\nJen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","In Process","Application Submitted","","","","2024-03-12","Application submitted via TMHP. Request ID:20441497. Your application has been submitted and is now under review. Your request number is: 20441497\nJen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","In Process","Application Submitted","","","","2024-03-12","Application submitted via TMHP. Request ID:20441497. Your application has been submitted and is now under review. Your request number is: 20441497\nJen Videan"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-03-20","1265872592","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-09-27","1265872592","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-03-08","6290221","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-01-30","13885700","","2024-01-30","01/30/2024 CAQH Reattested updated and uploaded license wthompson"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-01-23","P02003362","DW7662","2020-05-04","05/04/2020 - Verified and updated payer line - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-07-27","IMS complete"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-10-05","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 10/5/2016.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-02-15","1265872592","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 2-15-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-23","1265872592","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN/Service Location - Stacey Hudak\n\n**rec'd confirmation that this provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1265872592","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","363331502","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is effective with this group TPI 364596201 and linked to the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-01-23","512648ZV0W","519061","2020-04-20","04/20/2020 - confirmed provider EFF through PECOS group enrollment - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1238661","","2021-01-01","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1265872592","","2020-11-02","11/2/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1649713595","","2020-07-27","IMS  complete"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-11-17","P01787070","DW7662","2020-05-04","05/04/2020 - verified and moved to effective status - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-05-29","1649713595","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 5-29-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Provider Load","CAQH Reattested","2024-03-18","","","2024-03-18","03/18/2024 CAQH Sweep wthompson"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Re-Credentialing","2016-12-15","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1649713595","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312372","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Re-Credentialing","2020-09-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2016-12-15","1649713595","","2020-04-30","04/30/2020 - confirmed this provider/service location are linked to TIN through payer portal - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1649713595","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-11-17","1649713595","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2021-03-01","367256001","364596201","2021-03-01","3/1/2021 Received nofication TMHP revalidation has been completed successfully and provider is due for revalidation 2/25/2026. KFrazier"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Re-Credentialing","2020-04-03","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Re-Credentialing","2019-09-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-10-01","1649713595","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the primed roster - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Re-Credentialing","2020-03-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-03-12","1649713595","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Re-Credentialing","2017-02-23","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing","2020-08-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-11-17","553519ZV0W","519061","2020-04-20","04/20/2020 - verified completed enrollment through group PECOS - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2017-05-14","P01880121","DW7662","2020-05-04","05/04/2020 - verified and moved to effective status - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2017-05-14","579253ZV0W","519061","2020-04-20","04/20/2020 -confirmed provider is EFF through group enrollment in PECOS - Stacey Hduak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-04-03","1013456649","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2017-06-06","1013456649","","2020-06-05","06/05/2020 - Rec'd an email from the payer stating this provider is EFF - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1013456649","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312317","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2022-12-15","3546231","","2023-03-06","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 12/15/2022. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3546231. Physical location is on file. - DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-02-01","1013456649","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 2-1-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2020-05-08","1013456649","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 05/08/2020 under the group and TIN#. Provider is direct contract with Aertna. Physical location is on file. Call ref# 5309689188. - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2017-05-17","372790101","364596201","2022-02-08","2/8/2022 Per TMHP web portal license has been updated.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2019-09-01","","","2020-11-06","11/6/2020 Received email from United_Healthcare_Provider_Operations@uhc.com confirming provider is loaded under Group Tax ID and location for reference number PR-5512953 and assigned internal MPIN 006569937. Kimberly Frazier"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2017-06-01","1013456649","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1013456649","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service locatin and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","IMS complete"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-04-20","1013456649","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-01-01","3382000","","2020-06-08","06/8/2020 - Rec'd email from the payer stating this provider/address is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-01-07","761311","0008AH","2020-04-27","04/27/2020 - Confirmed enrollment through GROUP PECOS enrollment - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","0669817","","2021-07-06","7/6/2021 Received an email from PDMCOGZ@cigna.com confirming provider is participating under group Tax ID effective 3/31/2021, with assigned ID 0669817. KFrazier"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-05","1396930426","West Texas Physicians Alliance","2020-09-28","09/28/2020 - moved to completed status after receiving a spreadsheet from the payer stating this provider is EFF with West Texas Physicians Alliance under the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-05","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 4/5/2019.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019 - Jesriel Segovia"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-26",""]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-01-31","1396930426","","2020-04-23","04/23/2020--S/W Kim of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 1/31/2019. Physical Location is on file. Provider ID #9109842. Call ref # 5234162545\ncopied note from spreadsheet-tisha rader"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-01","","","2021-04-02","4/2/2021 Per Humana Military Portal provider is certified and linked to group TIN and location effective 5/1/2020.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2323463","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-03-20","03/20/2020 - Rec'd email from the payer (multiplan/true texas choice) stating this provider/service location is EFF with amerigroup - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","283737907","079837301","2020-01-29","01/29/2020 - found provider PAR through Medicaid portal. Provider is linked to the following plans: Texas Children's Health Plan - Harris, UnitedHealthcare Community Plan - Harris, UnitedHealthCare Community Plan - Harris - Mmp, Texas Children's Health Plan - Jefferson, UnitedHealthcare Community Plan - Jefferson, TRADITIONAL MEDICAID, Texas Children's Health Plan - Harris, Texas Children's Health Plan - Jefferson, Texas Children's Health Plan - MRSA Northeast, United Healthcare - Texas - Harris, United Healthcare - Texas - Jefferson, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-05-01","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-11-01","","","2020-11-25","11/25/2020 -  Rcvd email confirmation that Oct monthly roster was processed and this provider was made effective with the requested eff date of 11/1/2020.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2019-04-04","1396930426","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2323463","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1497985188","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-25","1497985188","","2020-08-20","8/20/2020 - Rec'd spreadsheet from the payer stating this provider has been affiliated with PRIMED DELEGATED AGREEMENT under this TIN/Service Location. Provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]

{"sheet":"TaxIDSearch","index":2,"n_rows":3,"n_cols":11,"rows_kept":3,"cut":false,"hidden":true,"merged":[]}
["Provider Name","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indiv ID #","Group ID#","Note Date","Notes","Symplr Rep"]
["Vikram R Vadyala, MD","PE - Vikram Vadyala, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19",1497985188,null,"2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vikram R Vadyala, MD","PE - Vikram Vadyala, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-25",1497985188,null,"2020-08-20","8/20/2020 - Rec'd spreadsheet from the payer stating this provider has been affiliated with PRIMED DELEGATED AGREEMENT under this TIN/Service Location. Provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]

{"sheet":"NPISearch","index":3,"n_rows":3,"n_cols":11,"rows_kept":3,"cut":false,"hidden":true,"merged":[]}
["Provider Name","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indiv ID #","Group ID#","Note Date","Notes","Symplr Rep"]
["Vikram R Vadyala, MD","PE - Vikram Vadyala, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19",1497985188,null,"2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vikram R Vadyala, MD","PE - Vikram Vadyala, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-25",1497985188,null,"2020-08-20","8/20/2020 - Rec'd spreadsheet from the payer stating this provider has been affiliated with PRIMED DELEGATED AGREEMENT under this TIN/Service Location. Provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]