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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","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","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","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","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","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Douglas J Colson, MD","1790767119","75-2656723","TX","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","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","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-04","","","2025-06-03","Location updates complete. Provider showing active at 4214 Andrews Hwy Ste 103 and 240. Jen Videan"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","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","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","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","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","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","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","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","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-07-19","","","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","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","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","Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-10-13",""]
["Douglas J Colson, MD","1790767119","75-2656723","TX","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","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","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-02-22","","","2024-03-20","Welcome ltr rcvd. Provider effective at this location 02/22/2023. Jen Videan"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","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","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-23","11483093","","2025-09-23","09/23/2025 CAQH Reattested-updated Edu and updated Cred Cont address-dvineyard"]
["Douglas J Colson, MD","1790767119","75-2656723","TX","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"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","","","2020-09-11",""]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","CAQH","In House Enrollment","In House Enrollment","","","","2025-07-25","7/25/2025 Per email from Jennifer Videan providers CAQH profile is now Client Maintains-dvineyard"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2025-03-25","Received welcome letter. MS"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2025-03-25","Received welcome letter. MS"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2025-05-05","Address was loaded to current enrollment record. MS"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2025-05-05","Address was loaded to current enrollment record. MS"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","382485601","079837301","2025-06-09","Last name has been updated to Brown and address, 3620 N Big Spring St Midland TX has been added effective 05/05/2024. Jen Videan"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-06-15","1023520830","","2020-10-05","Enrolled thru PHCS"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Active","CAQH Reattested","2025-05-08","14145595","","2025-03-19","3/19/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","IMS is complete"]
["Lori Ann Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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 Brown, APRN-FNP-BC","1023520830","75-2656723","TX","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"]
["Coby R Robins, MD","1104237015","75-2133441","TX","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","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","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","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","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","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","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","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","Midland Pediatric Associates, PLLC","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-17","07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Coby R Robins, MD","1104237015","75-2133441","TX","Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2025-09-02","14218808","","2025-09-02","09/02/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Coby R Robins, MD","1104237015","75-2133441","TX","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","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","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"]
["Coby R Robins, MD","1104237015","75-2133441","TX","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","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","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"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","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","75-2656723","TX","","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","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","BCBSTX","Participating","Enrollment Complete","2024-04-09","","","2024-04-08","Received email provider is now PAR and participating with the following networks, eff. 4/9/2024:\nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nMCH - Medicare Advantage HMO\nSNP - Dual Eligible Special Needs Plan\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO\nWEL - WellMed MA HMO. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-10-09","","","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","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-10-09","","","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","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted","2023-10-09","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","HealthSmart PPO","Participating","Add Info Submitted","2023-10-09","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2025-01-24","Received email confirmation provider is par, linked to TIN & location, eff. 9/13/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Par through Multiplan enrollment, eff. 11/06/2023. PA"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","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","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","75-2656723","TX","","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","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Humana","Participating","Enrollment Complete","2023-10-09","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Rail Road Medicare","No Enrollment Required","No Enrollment Required","","","","2024-04-25","Due to the type of Medicare enrollment, this enrollment is not required. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Wellmed","Participating","Enrollment Complete","2024-02-06","","","2025-01-24","Received product roster. Provider is par, linked to TIN/location, eff. 02/06/2024. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Wellcare","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Medicare","No Enrollment Required","No Enrollment Required","","","","2024-04-08","Enrollment not required as the type of enrollment is unable to have providers reassigned. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","IMS","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","IMS","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","IMS","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","IMS","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","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","City of Midland Health Department","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-01-08","Received email from payor confirming provider is PAR, linked to TIN/location, eff. 11/1/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2024-01-01","","","2024-08-09","Received notification via email Dr. Ammu par as of 1/1/2024. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Multiplan","Participating","Enrollment Complete","2024-02-06","","","2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Multiplan","Participating","Enrollment Complete","2024-02-06","","","2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Multiplan","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Multiplan","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Ambetter","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","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","75-2656723","TX","","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","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Omni PPO","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Omni PPO","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Omni PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Omni PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete","2024-02-06","","","2024-04-16","Received email from Karen Avalos confirming roster completed; provider is PAR under TIN: 75-6000608, eff. 2/06/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-11-06","8007338","","2025-08-11","08/05/2025 MP: Called 1-800-353-1232 and spoke w Rald at Aetna. Stated provider is PAR with GRP and TIN effective 11/06/2023. PIN is 8007338. Loc not on file. To add, submit LOI with W9 via FAX 859-455-8650 Attn to. Network Management. Call ref 256059921."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2025-05-23","","","2025-06-05","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","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","75-6000608","TX","City of Midland Health Department","Cigna","Participating","Enrollment Complete","2024-02-01","0446524","","2024-09-05","Received confirmation email. MS"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Add Info Submitted","2023-11-01","","","2025-09-08","Reference #20780008 - Adding address of suite 240 has been submitted 9/8/2025 (rp)"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","HealthSmart PPO","Participating","Enrollment Complete","2024-02-06","","","2024-07-04","7/4/2024 provider participating as of 2/6/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","HealthSmart PPO","Participating","Enrollment Complete","2024-02-06","","","2024-07-04","7/4/2024 provider participating as of 2/6/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","HealthSmart PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","HealthSmart PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Cigna Healthspring","Panel Closed","Panel Closed","","","","2024-04-18","Received letter the panel is closed. MS"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Medicaid","Participating","Enrollment Complete","2024-09-03","","","2024-10-25","Welcome ltr rcvd. Effective 09/03/2024. Jen Videan"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","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","City of Midland Health Department","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-17","07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2023-10-09","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","United Health Care","Participating","Enrollment Complete","2024-02-06","","","2024-11-19","Received product roster from UHC. Provider is listed PAR, linked to TIN & location, eff. 2/6/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Amerigroup","Participating","Enrollment Complete","2024-02-06","","","2025-02-13","As per Mindy Wiggins via Teams meeting 2/13/2025,  provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-04-25","","","2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","First Health Coventry","Participating","Enrollment Complete","2024-04-01","","","2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","First Health Coventry","Participating","Enrollment Complete","2024-04-01","","","2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","First Health Coventry","Participating","Add Info Submitted","2024-04-01","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","First Health Coventry","Participating","Add Info Submitted","2024-04-01","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","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","City of Midland Health Department","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20","","","2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20","","","2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Superior","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-10-09","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Humana","Participating","Enrollment Complete","2023-10-09","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA"]
["Anusha Ammu, MD","1386135713","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Add Info Submitted","2023-10-09","","","2025-04-15","Submitted request via delegated roster to have 2012 Ohio location removed and ensure provider is linked to 400 Rosalind Redfern location. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","","Humana","Participating","Add Info Submitted","2023-10-09","","","2025-04-15","Submitted request via delegated roster to have 2012 Ohio location removed and ensure provider is linked to 400 Rosalind Redfern location. PA."]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","PPHP","Participating","Enrollment Complete","2024-04-25","","","2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","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","City of Midland Health Department","Aetna","Participating","Enrollment Complete","2024-02-06","8007338","","2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Aetna","Participating","Enrollment Complete","2024-02-06","8007338","","2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Aetna","Participating","Payor Follow Up","2024-02-06","8007338","","2024-07-17","As per Dennis R call ref#6198039875, suite number is not tied to TIN. I will fax a letter of intent to 859-455-8650 for demographic update to add suite 22. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","","Aetna","Participating","Payor Follow Up","2024-02-06","8007338","","2024-07-17","As per Dennis R call ref#6198039875, suite number is not tied to TIN. I will fax a letter of intent to 859-455-8650 for demographic update to add suite 22. FC"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","City of Midland Health Department","Triwest VA","Thru Other Payor","Payor Follow Up","","","","2024-08-19","Requested status update on enrollment via email to Scarlett Abigail. PA."]
["Anusha Ammu, MD","1386135713","75-2656723","TX","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","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2023-11-06","","","2024-04-11","4/11/2024 As per Cassandra (WellPoint rep) Dr. Bennion is par effective 11/6/2023. FC"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","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","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","Midland Community Healthcare Services","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","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","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","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","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","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","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","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","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","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","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","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","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"]
["Glen Allen Bennion, DO","1386132876","83-0358685","TX","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","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"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","","2023-09-06","Confirmed this provider was added. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","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","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","008092273","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 3/1/2024. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-10-13","","","2024-05-02","Received email from Marcus Wester (mwester@humana.com) provider has been linked to location, eff. 10/13/2023. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23"," 1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","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","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","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","","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","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","","Omni PPO","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-02-01","6819516","","2024-01-09","Received confirmation of enrollment. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd. 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is in network with the TIN3. Location is on file. PIN 6819516. Call ref# Jay 08/06/2025"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd. 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is in network with the TIN3. Location is on file. PIN 6819516. Call ref# Jay 08/06/2025"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd. 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is in network with the TIN3. Location is on file. PIN 6819516. Call ref# Jay 08/06/2025"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd. 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is in network with the TIN3. Location is on file. PIN 6819516. Call ref# Jay 08/06/2025"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-12-03","","","2024-12-03","Location is added to group record and provider is linked to group. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","","","2025-06-23","Received confirmation via email from Mary Hanna, provider participating as of 10/7/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1841780806","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location except 6301 Andrews Hwy. PIN is NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","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","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","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","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","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","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","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","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","2025-08-26","08/26/2025 CAQH Reattested-updated Cred Cont-dvineyard"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Payor Follow Up","","","","2024-04-30","Sent email to Multiplan rep Marcie Havens (marcie.havens@multiplan.com) requesting enrollment status update. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024 location has been added, eff. 1/1/2020. PA"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","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","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","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","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1841780806","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-08-01","","","2024-06-21","Received confirmation from Marcus Wester provider is PAR and linked to TIN/location, eff. 08/01/2023. PA"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2025-06-27","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 9/13/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-14","","","2025-03-24","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 06/14/2022. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-07-01","","","2024-06-28","Group enrollment has been approved and this location has been linked and is active effective 7/1/2024. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","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","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","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2024-10-31","Received confirmation via delegated roster provider participating as of 7/1/2022. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","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","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-07-24","","","2025-02-17","Received email confirmation provider is enrolled, linked to TIN/location, eff. 07/24/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-07-15","","","2024-07-19","Received roster from HP Delegation; provider is PAR and linked to TIN and location, eff. 7/15/2022. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","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","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","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-28","1841780806","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI. Loc not on file."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","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","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","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","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","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-07-26","","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","","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","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","","IMS","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-07-15","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff.  7/15/2022. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-01-22","","","2025-01-22","Received confirmation via BCBSTX email Provider participating. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-10-16","No updates are needed at the individual level for RR MCR when adding a new location unless that location will be updated to the primary location. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-12-03","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 12/03/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","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","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","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-10","","","2024-07-01","Provider is confirmed. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-12-02","6819516","","2025-02-24","Received confirmation from Cigna. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-25","","","2024-07-02","Received email from Angela Bates confirming location has been added to provider’s record, eff. 06/25/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-07-15","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff.  7/15/2022. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","1841780806","","2024-02-13","Provider effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","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","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","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","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","WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-05-17","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-28","1841780806","","2024-07-05","Per michelle.killough@pswca.org, 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"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-07-03","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff 07/03/2022. PA"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-28","1841780806","","2024-07-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1841780806","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2023 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","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","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-01","","","","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 06/01/2022, and linked to 616 Main St. location. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","","First Health Coventry","Participating","Enrollment Complete","2022-06-01","","","","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 06/01/2022, and linked to 616 Main St. location. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2022-06-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","","First Health Coventry","Participating","Application Resubmitted","2022-06-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-01","","","2024-07-04","7/4/2024 provider participating as of 2/1/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","000008092273","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","000008092273","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","000008092273","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","000008092273","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-28","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-12-03","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 12/03/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2022-07-03","00008092273024","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","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","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","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","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","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-18","Received email confirmation from PPHP, provider is linked to the location/TIN, eff. 7/11/2024. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","  1841780806","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-14","","","2025-03-24","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 06/14/2022. PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2024-02-13","Please see status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","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","","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","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","","IMS","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-02-20","7M9102","","2025-06-25","Per PECOS provider is active and linked to group. Location is active. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","Tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","Tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-07-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/03/2022.  PA."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2025-02-04","Recceived confirmation via email from LaNetrice Myart, provider participating as of 9/13/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","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","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","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","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","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","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","","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","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2022-06-01","3567571","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","","First Health Coventry","Participating","Application Resubmitted","2022-06-01","3567571","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2017-09-01","","","2025-08-18","08/15/2025 AC: Checked Texas Mutual's directory to check provider status, provider is participating. Verification request has been emailed to wwtxcontracts@texasmutual.com to verify provider effective date."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-01","","","2024-05-20","5/202/24 Spoke to Alex call ref#6192816326 616 N Main St  location participating as of 02/1/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-07-01","","","2025-08-13","08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is in network with the TIN effective 07/01/2024. Location is on file. PIN 6819516. Call ref# Jay 08/06/2025"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","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","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","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","1841780806","","2024-11-14","Please see status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","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","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","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","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","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","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 AC: Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 AC: Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-05-01","","","2024-05-09","Received email from Marina Martinez of USA MCO, provider is PAR and 616 Main St location linked, eff. 05/01/2024."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","2025-09-23","CAQH reattestation complete - Information up to date - Next attestation due on 1/21/2026. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","2025-09-23","CAQH reattestation complete - Information up to date - Next attestation due on 1/21/2026. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","2025-09-23","CAQH reattestation complete - Information up to date - Next attestation due on 1/21/2026. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","2025-09-23","CAQH reattestation complete - Information up to date - Next attestation due on 1/21/2026. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","2025-09-23","CAQH reattestation complete - Information up to date - Next attestation due on 1/21/2026. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","2025-09-23","CAQH reattestation complete - Information up to date - Next attestation due on 1/21/2026. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","2025-09-23","CAQH reattestation complete - Information up to date - Next attestation due on 1/21/2026. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","","","2025-09-23","CAQH reattestation complete - Information up to date - Next attestation due on 1/21/2026. ML"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","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","","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","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","","Omni PPO","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","1841780806","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 5/17/2023 for all locations. NPI# is PIN."]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","1841780806","","2024-11-14","Per Michelle Killough at michelle.killough@pswca.org location has been added to group profile. 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"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2023-08-02","Rcvd approval letter from TMHP. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-04-14","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 1/26/2017 for all locations. PIN is the NPI."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Zurich","Participating","Thru Other Payor","2023-05-25","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","","Zurich","Participating","Thru Other Payor","2023-05-25","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2023-05-25","","","2024-09-13","9/13/2024 As per John (call ref#18150839) provider participating as of 5/25/2023. FC"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","","Zurich","Participating","Enrollment Complete","2023-05-25","","","2024-09-13","9/13/2024 As per John (call ref#18150839) provider participating as of 5/25/2023. FC"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","TriWest HC Alliance","Participating","Payor Follow Up","2023-04-14","","","2025-06-05","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2023-05-19","1225283963","","2025-05-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1225283963","","2025-05-28","Per providerdata@careworks.com, name change request has been processed. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2023-04-14","","","2025-04-14","Received email from Karen Avalos confirming February roster was processed. Provider par, eff. 04/14/2023. PA."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","1225283963","","2025-04-28","Per updates@primehealthservices.com, Her last name is Lucas. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","1225283963","","2025-04-28","Per updates@primehealthservices.com, Her last name is Lucas. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","1225283963","","2025-09-08","09/08/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 1/11/2024 all locations but providers last name is different. PIN is NPI."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","1225283963","","2025-09-08","09/08/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 1/11/2024 all locations but providers last name is different. PIN is NPI."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2023-05-25","","","2024-04-25","4/25/2024 provider participating as of 5/25/2023 via roster. FC"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 AC: Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-08-21","Received confirmation. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2023-05-19","1225283963","","2025-04-28","Per michelle.killough@pswca.org, I have downloaded her license reflecting the change. I will make it in our system. Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2T0202","","2025-05-01","The application to update the providers last name has been approved. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Humana","Participating","Confirm Par Status","2023-07-01","","","2025-02-11","Received email confirmation provider is par, linked to TIN & location, eff. 07/01/2023. PA"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2025-09-23","","","2025-10-07","CAQH Reattested. All information updated and completed. ML"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-17","07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2023-08-01","","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 8/1/2023 for all locations. PIN is the NPI."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2024-04-05","","","2025-03-04","Received confirmation via email from First Health, provider par as of 4/5/2024 under last name Wood. FC"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2025-05-30","Name change has been approved and closed (Wood to Lucas). Jen Videan"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-18",""]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27",""]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","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 Lucas, PA","1225283963","46-3131679","TX","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","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","Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","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","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","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-06-06","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","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","Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete","1991-09-01","","","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Zurich","Thru Other Payor","Thru Other Payor","","","","2024-10-01","See Coventry payor line for updates. Jen Videan"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","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","Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: Verification request has been emailed to TXMAContracting@CignaHealthcare.com to verify provider credentialing status."]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","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","Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-04-08","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 04/08/2025 for all locations. PIN is the NPI."]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","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","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","Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","","1740542034","","2024-10-08","Per SPNEAST@sedgwickcms.com, provider is already credentialed in their Network. Provider was with CareWorks before Sedgwick acquired them & they do not have access to letters from that time. Jen Videan"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-08-01","","","2025-06-27","Received confirmation via email from Coventry cssupport@cvty.us.com, provider participating as of 8/1/2024. FC"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","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","Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-08-12","08/12/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","1740542034","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","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","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","Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25","1740542034","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-12-06","","","2024-09-09","Confirmed provider is linked to this location. MS"]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","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","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","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","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","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","Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1740542034","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2018-08-01","1740542034","","2025-08-08","08.04.2025 JB: Verification request has been emailed to updates@primehealthservices.com, credentialing@primehealthservices.com, providerrelations@primehealthservices.com to verify provider credentialing status."]
["Ryan S Rowland, MD","1740542034","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","2018-08-01","","","2024-09-19","Approval ltr rcvd. Jen Videan"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2025-05-05","","","2025-09-08","Received notification via online chat box (spoke with Derek, ref. # 05415338) confirming provider's participation with network effective 05/05/2025. ML"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2018-08-01","","","2025-08-18","08/18/2025 AC: Called 1-800-353-1232 and spoke w Madie R at Aetna. Stated provider is PAR but not link to TIN need to submit link letter through fax#: 8594558650, attn to: network management and attach w9 form. TAT: 30 bus days PIN: 6125319. Call ref number 259521106"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","PPHP","Participating","Enrollment Complete","2025-05-05","","","2025-05-27","Received email from Keandra W. confirming  May roster has been processed. Provider now linked to TIN/location, eff 5/5/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2025-05-05","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Location effective 5/5/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","IMS","Participating","Enrollment Complete","2025-05-05","","","2025-05-22","Received confirmation via email from Addella Yarnold from IMS, provider participating as of 5/5/2025. FC"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2025-04-01","Q01054587","","2025-06-18","Provider approved. MS"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","TriWest HC Alliance","In Process","Confirm Par Status","","","","2025-10-06","Emailed tricareproviderinquiries@triwest.com for status. Jen Videan"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2025-05-05","","","2025-07-10","Received confirmation via email from Emily Starr, provider participating eff 5/5/2025. FC"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2025-05-05","","","2025-07-16","Received email from Marcus Wester confirming provider is par, linked to TIN/location, eff. 5/5/25. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2025-04-01","","","2025-06-26","Approval ltr rcvd. Effective 04/01/2025. Jen Videan"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","BCBSTX","Participating","Enrollment Complete","2025-05-23","","","2025-05-28","Received welcome letter from BCBSTX confirming the provider is participating, linked to group,  effective 05/23/2025. The provider is enrolled in the following networks: BCA - BlueChoice PPO, HME - Health Select, HMO - Blue Essentials, WEL - WellMed MA HMO, BAV - Blue Advantage HMO, MCH - Medicare Advantage HMO, PMC - Medicare Advantage PPO, and SNP - Dual Eligible Special Needs Plan. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2025-09-02","3970095","","2025-09-03","Per discovercigna@information.cigna.com,  Dear SULAY PATEL, Congratulations! It is my pleasure to welcome you to the Cigna HealthcareSM medical network. Physicians like you – and the care teams that surround you – are essential to ensuring the health and vitality of your patients. \n\n•\tYour effective date is 09/02/2025.\n•\tYour provider identification number is 3970095. Jen Videan"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2025-05-05","","","2025-06-27","Received email from Karen Avalos confirming provider is linked to TIN/location, eff. 5/5/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2025-06-01","","","2025-08-05","Received email from BSW confirming provider is par, linked to TIN/location, eff. 06/01/2025. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Amerigroup","In Process","Application Submitted","","","","2025-05-15","Application submitted via delegated roster. FC"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2025-05-05","","","2025-05-22","Received confirmation via email from Addella Yarnold from IMS, provider participating as of 5/5/2025. FC"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2025-05-05","","","2025-09-08","Received notification via online chat box (spoke with Derek, ref. # 05415338) confirming provider's participation with network effective 05/05/2025. ML"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2025-08-15","","","2025-08-15","08/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2025-04-01","7N6523","","2025-05-22","Received welcome letter. MS"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Triwest VA","Participating","Enrollment Complete","2025-09-15","","","2025-09-11","Received email from scarlett_abigail@bcbstx.com stating provider is now completed with effective date of 09/15/2025. MR"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2025-05-05","","","2025-06-27","Received confirmation vial email from Mary Rodriguez, provider participating eff date 5/5/2025. FC"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","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","Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete","","","","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","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","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","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","Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-09-09","09/09/2025 Per email CAQH Reattested-all information is correct and up to date-dvineyard"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","2020-01-05","412587401","325373401","2024-09-09","Per TMHP provider still showing effective/active and linked 01/05/2020. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-04-08","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 04/08/2025 for all locations. PIN is the NPI."]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","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","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","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","Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","1346807278","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","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","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","Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","","1346807278","","2024-10-08","Per SPNEAST@sedgwickcms.com, provider is already credentialed in their Network. Provider was with CareWorks before Sedgwick acquired them & they do not have access to letters from that time. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","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","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","2021-01-26","1312287","","2025-07-17","07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","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","Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2020-01-05","Q00111613","DU2795","2025-02-20","Enrollment Confirmed. MS"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-07-02","","","2024-09-09","Provider has been confirmed linked to this location. MS"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-09-19","09/19/2025 AC: Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","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","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","Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1346807278","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Zurich","Thru Other Payor","Thru Other Payor","","","","2024-10-01","See Coventry payor line for updates. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","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"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","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","Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25"," 1346807278","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-08-01","","","2025-06-27","Received confirmation via email from Coventry cssupport@cvty.us.com, provider participating as of 8/1/2024. FC"]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-06-06","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Pamela F Doughty, PA","1346807278","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2024-08-29","Received confirmation from Cassandra Dunagon provider is participating with all products. FC"]
["Gautham S Gadiraju, MD","1649462987","47-5554737","TX","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","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-09-09","09/09/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Gautham S Gadiraju, MD","1649462987","47-5554737","TX","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","Midland Inpatient Medical Association","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Gautham S Gadiraju, MD","1649462987","47-5554737","TX","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","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","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","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","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","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","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","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","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","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"]
["Gautham S Gadiraju, MD","1649462987","47-5554737","TX","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","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","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"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","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","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","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","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","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","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","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-09-09","09/09/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","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","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","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","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","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","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","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","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","Midland Inpatient Medical Association","TriWest HC Alliance","Participating","Payor Follow Up","2018-11-15","1407149883","","2025-07-17","07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-25",""]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","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","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","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","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","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"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","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","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"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2024-03-11","","","2024-06-03","Per Aetna rep Irish G, 1-800-353-1232, reference #6194100173, provider is  PAR, effective 3/11/2024, linked to TIN and location. PA"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2024-03-11","","","2024-08-30","Received confirmation via email from Aleece Moerbe provider participating as of 3/11/2024. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2024-03-11","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  03/11/2024.  PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2024-04-15","","","2024-09-04","Roster received from the payor. The provider is listed as PAR, effective  4/15/2024, and is linked to the TIN and location. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2024-02-12","7487489","","2024-04-05","Received confirmation of enrollment via email. MS"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2024-03-13","","","2024-08-08","Provider PAR with Star, Star kids, and Star + eff date 3/13/2024 as per roster received from Cassandra via email. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","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","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2024-04-01","","","2024-08-08","Provider participating as of 4/1/2024 listed as Pediatrics, spoke to Tash call ref#11607782. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-03-19","Pending UHC enrollment. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2024-03-12","","","2024-04-29","Provider is linked to this location eff 3/12/24. MS"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-12-28","","","2024-08-16","Received confirmation from Mary Rodriguez via e,mail, provider participating as of 12/28/2023. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2024-03-11","","","2024-08-16","Received confirmation from Jessica Bess via email provider participating as of 3/11/2024. FC"]
["Kevin W Benson, MD","1326061086","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2024-03-11","","","2024-08-08","Received confirmation provider is PAR and linked to TIN/location, eff. 3/11/2024. Product roster uploaded. PA."]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","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","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","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","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","Andrews County Hospital District","Molina","In Process","Payor Follow Up","","","","2025-08-25","08/25/2025 AC:  Called 1-855-322-4080 and spoke w Rove at Molina. Stated that prov is out of network, unable to check applications. Rep advise to email Contracting Team at mhtcontractrequest@molinahealthcare.com. Verification request has been emailed to mhtcontractrequest@molinahealthcare.com. to verify provider credentialing status."]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","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","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","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","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","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","Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2020-09-01","6427230","","2025-08-12","08/05/2025 TE: Called 1-800-353-1232 and spoke with Tine at Aetna. Provider is linked to the TIN as in network effective 09/01/2020. Location is on file. PIN 6427230. Call ref# 256067362"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","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","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","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","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","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","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","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","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","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","Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2025-08-07","","","2025-08-07","08/07/2025 CAQH Reattested-updated Cred Cont-dvineyard"]
["Ubaldo Estrada, FNP","1740723725","75-1997880","TX","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","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"]
["John W Mathewson, MD","1588857874","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2019-05-10","1588857874","","2024-07-24","Approval Ltr rcvd. Effective 05/10/2019. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Confirm Par Status","2020-04-03","1588857874","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of 04/03/2020. PA."]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 AC: Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["John W Mathewson, MD","1588857874","46-3131679","TX","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","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","Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2020-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-10-07","CAQH Reattested. All information up to date. ML"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","","","2024-08-22","Revalidation approval ltr rcvd. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1588857874","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["John W Mathewson, MD","1588857874","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2024-10-01","2650428","","2025-03-04","Received confirmation via email from First Health, provider par as of 10/1/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2019-05-10","1588857874","","2024-07-24","Please see status updates under Alliance WC payor line. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","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","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","Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-06-01","1588857874","","2025-01-16","Received email confirmation on 01/07/2025 confirming provider reinstated with an effective date of 06/01/2019 for Aetna commercial plans and IFP/ Exchange CVS HMO plan. PA."]
["John W Mathewson, MD","1588857874","46-3131679","TX","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","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","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","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","Midland Texas Orthopedic Group Inc","Humana","Participating","Confirm Par Status","2020-04-03","1588857874","","2025-02-11","Received email confirmation provider is par, linked to TIN & location, eff. 04/03/2020. PA"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-04-27","1588857874","","2024-05-07","Provider active with Corvel. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 5/1/2019 for all locations. PIN is the NPI."]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","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","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","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","Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2021-02-12","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2020-04-03","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["John W Mathewson, MD","1588857874","46-3131679","TX","Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","1588857874","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["John W Mathewson, MD","1588857874","46-3131679","TX","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","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","Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2025-05-01","","","2025-06-27","Received confirmation via email from Coventry cssupport@cvty.us.com, provider participating as of 5/1/2025. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1164778767","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2021-02-12","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","","   1164778767","","2025-08-27","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/01/2019 for all locations. PIN is the NPI."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2019-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2025-09-15","","","2025-10-07","CAQH Reattestation completed. All information correct & up to date. ML"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2022-11-18","1164778767","","2024-09-10","Please see status updates under Alliance WC payor line. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 AC: Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-12-31","","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 01/26/2017 for all locations. PIN is the NPI."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","1164778767","","2025-08-27","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/01/2019 for all locations. PIN is the NPI."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Humana","Participating","Confirm Par Status","2020-03-20","1164778767","","2025-02-11","Received email confirmation provider is par, linked to TIN & location, eff. 03/20/2020. PA"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2022-11-18"," 1164778767","","2024-09-10","Welcome ltr rcvd. Effective 11/18/2022. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Confirm Par Status","2020-03-20","1164778767","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of 03/20/2020. PA."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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","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","Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2024-10-01","3039403","","2025-03-04","Received confirmation via email from First Health, provider par as of 10/1/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2020-03-20","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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","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","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","Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-06-01","","","2025-01-16","Received email confirmation on 01/07/2025 confirming provider reinstated with an effective date of 06/01/2019 for Aetna commercial plans and IFP/ Exchange CVS HMO plan. PA."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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","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","Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 01/11/2024 for all locations. PIN is the NPI."]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2020-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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","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","Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2024-08-01","","","2025-06-27","Received confirmation via email from Coventry cssupport@cvty.us.com, provider participating as of 8/1/2024. FC"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2024-06-01","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 6/1/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2025-05-23","13859704","","2025-06-04","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","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, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-12-02","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 12/2/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff. 10/15/2019. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2025-08-11","08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is participating and link under the group and TIN PIN is 2017791. Physical location is on file. Call ref# Aby S 08/05/2025."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-05-01","P02252784","","2024-12-20","Confirmed providers enrollment. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2019-07-05","","","2025-05-27","Received product roster from UHC rep, Charlie. Suite 103 location successfully added. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 5/31/2019. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-03","","","2025-01-30","Received confirmation via email from Caprock, provider participating as of 5/3/2019. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","","","2025-02-21","Received email from Network Relations-Humana, confirming provider is par, linked to TIN/location, eff.  01/1/2020. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-06-01","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 06/01/2024. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","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, APRN-FNP-BC","1639524861","75-2656723","TX","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, APRN-FNP-BC","1639524861","75-2656723","TX","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, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-01-16","","","2025-03-25","Approval ltr rcvd. Effective 01/16/2024. Jen Videan"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","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, APRN-FNP-BC","1639524861","75-2656723","TX","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, APRN-FNP-BC","1639524861","75-2656723","TX","","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, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Application Resubmitted","2019-05-31","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","","Amerigroup","Participating","Application Resubmitted","2019-05-31","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-06-01","","","2025-02-03","Received  confirmation via email from Karen Avalos, provider participating as of 6/1/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","CAQH","Active","CAQH Reattested","","","","2025-09-19","CAQH profile up to date/all information correct. Next attestation due on 1/17/2026. ML"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","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, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-07-05","","","2025-05-27","Received product roster from UHC rep, Charlie. Suite 103 location successfully added. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","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"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-12-02","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 12/2/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-01","","","2025-02-04","Received confirmation via email from Jessica Bess, provider participating as of 6/1/2024. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-26",""]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Omni PPO","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-26",""]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Omni PPO","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","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","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","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","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","","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","Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Add Info Submitted","2019-09-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","HealthSmart PPO","Participating","Add Info Submitted","2019-09-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1144665233","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: Verification request has been emailed to TXMAContracting@CignaHealthcare.com to verify provider credentialing status."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Add Info Submitted","2019-08-26","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2019-08-26","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2025-04-08","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 04/08/2025 for all locations. PIN is the NPI."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete","2019-09-01","842726","270548","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS   Eff 8/2024, Symplr will now manage. MS"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","2019-09-01","1144665233","","2024-07-08","Revalidation approved. Effective 09/01/2019. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Sedgwick","In Process","Enrollment Complete",""," 1144665233","","2025-09-16","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 09/17/2025 for all locations. PIN is the NPI."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","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","Urgent Orthopedic Specialists, PLLC","CAQH","Participating","Pending Info/Document","2025-03-06","","","2025-03-06","3/6/2025 unable to reattested invalid UN/PW-dvineyard"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-17","07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","1144665233","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","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","","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","Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Add Info Submitted","2019-09-01","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Multiplan","Participating","Add Info Submitted","2019-09-01","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","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","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","Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-08-01","","","2025-06-27","Received confirmation via email from Coventry cssupport@cvty.us.com, provider participating as of 8/1/2024. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","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","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","","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","Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Add Info Submitted","2020-04-15","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","Amerigroup","Participating","Add Info Submitted","2020-04-15","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2019-12-05","","","2024-09-09","Provider is linked to this location. MS"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Zurich","Thru Other Payor","Thru Other Payor","","","","2024-10-01","See Coventry payor line for updates. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25","1144665233","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","","","2025-07-15","Received confirmation via email from Brandy Smith provider participating effective 9/1/2020. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","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","Urgent Orthopedic Specialists, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2020-09-01","6694913","","2025-08-08","08.04.2025 JB: Verification request has been emailed to updates@primehealthservices.com, credentialing@primehealthservices.com, providerrelations@primehealthservices.com to verify provider credentialing status."]
["William Gage Liesman, MD","1144665233","46-0950925","TX","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","","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","Urgent Orthopedic Specialists, PLLC","IMS","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","","IMS","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Enrollment Complete","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2019-09-01","Q00007922","DU2795","2025-02-20","Confirmed Enrollment. MS"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","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"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","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","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","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"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","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","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","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","","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","Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-09","13876531","","2025-09-09","09/09/2025 CAQH Reattested-updated TX DEA and uploaded doc-dvineyard"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-09","13876531","","2025-09-09","09/09/2025 CAQH Reattested-updated TX DEA and uploaded doc-dvineyard"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-09","13876531","","2025-09-09","09/09/2025 CAQH Reattested-updated TX DEA and uploaded doc-dvineyard"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-09","13876531","","2025-09-09","09/09/2025 CAQH Reattested-updated TX DEA and uploaded doc-dvineyard"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","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","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","","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","Premier Family Care, Inc.","IMS","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","","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","Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-06-05","","","2025-08-11","08.05.2025 JJ: Called Cigna @ 1-800-882-4462 to obtain FU status of the provider and s/w Angela. Per rep, provider is in-network and linked to TIN with eff date 06/05/2023. PIN: 7585417. Physical location is on file. Call ref#: Angela H. 08/05/2025."]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","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","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","","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","Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","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","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","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","","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","Premier Family Care, Inc.","Omni PPO","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","","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","Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","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","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","","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","Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2019-07-20","1932541406","52669: West Texas Physicians Alliance Group Cntrct","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2019-07-20","1932541406","52669: West Texas Physicians Alliance Group Cntrct","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","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","","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","Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2019-06-12","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2019-06-12","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","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","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","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","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","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","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-21","1932541406","","2023-09-06","Downloaded approval letter from TMHP website. Effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","","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","Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted","2019-06-12","1932541406","","","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","HealthSmart PPO","Participating","Add Info Submitted","2019-06-12","1932541406","","","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",""," 1932541406","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",""," 1932541406","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",""," 1932541406","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",""," 1932541406","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-06-14",""]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2022-03-11","","","2025-09-15","Received email notification (tmongold@pphealthplan.com) confirming provider's participation with network under TIN/ Location effective 3/11/2022. ML"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","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","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","1528619525","","2024-08-21","Revalidation Approval Ltr rcvd. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","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","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-05","14530139","","2025-09-05","09/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","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","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","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","1528619525","","2025-03-17","Per TMHP, license has been updated and Megan is showing active again. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","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","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","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","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","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","Premier Family Care, Inc","TriWest HC Alliance","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","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","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","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","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","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-09-01","","","2025-08-12","08.05.2025 MG: Called Aetna @ 1-800-353-1232 to obtain PNP/FU status for the provider and spoke to Kristen. Per rep, NPI# is on file for the provider and is participating effective 09/01/2024 under the group and TIN#. Physical location is on file. Provider ID is 6345073. Call ref# 256064729."]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","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","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","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","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","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","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","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","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","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"]
["Megan Casselman, NP-C","1528619525","75-2656723","TX","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","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","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"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2025-03-04","Location is non network and does not require credentialing. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","2022-09-01","","","2025-06-05","For Locations:4214 Andrews Hwy Suite 103/400 Rosalind Redfern Grover Pkwy Suite 271/709 W Louisiana Ave/3411 Caldera/3415 N Loop 250/3620 N Big Spring/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240/ 06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","Aetna","In Process","Action Needed","","","","2025-07-16","For Locations: 4214 Andrews Hwy/ 400 Rosalind Redfern Grover Parkway siute 216/ 400 Rosalind Redfern Grover Parkway suite 271/ 07/15/2025 MQ: Called Aetna @ 800-353-1232 to obtain FU status of provider and spoke with Liz. Per rep provider is in network and linked effective 5/1/2023 under the grp/TIN. Next Re-cred is 5/1/2026. PIN:6669419. Loc is not on file. No request received. To add the loc, just send LOI along w/ W9 form via Fax# 8594558650 attn to Network Account Management. TAT is 30  bus days. Call ref#"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","In Process","Action Needed","","","","2025-07-16","For Locations: 4214 Andrews Hwy/ 400 Rosalind Redfern Grover Parkway siute 216/ 400 Rosalind Redfern Grover Parkway suite 271/ 07/15/2025 MQ: Called Aetna @ 800-353-1232 to obtain FU status of provider and spoke with Liz. Per rep provider is in network and linked effective 5/1/2023 under the grp/TIN. Next Re-cred is 5/1/2026. PIN:6669419. Loc is not on file. No request received. To add the loc, just send LOI along w/ W9 form via Fax# 8594558650 attn to Network Account Management. TAT is 30  bus days. Call ref#"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","In Process","Action Needed","","","","2025-07-16","For Locations: 4214 Andrews Hwy/ 400 Rosalind Redfern Grover Parkway siute 216/ 400 Rosalind Redfern Grover Parkway suite 271/ 07/15/2025 MQ: Called Aetna @ 800-353-1232 to obtain FU status of provider and spoke with Liz. Per rep provider is in network and linked effective 5/1/2023 under the grp/TIN. Next Re-cred is 5/1/2026. PIN:6669419. Loc is not on file. No request received. To add the loc, just send LOI along w/ W9 form via Fax# 8594558650 attn to Network Account Management. TAT is 30  bus days. Call ref#"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","In Process","Action Needed","","","","2025-07-16","For Locations: 4214 Andrews Hwy/ 400 Rosalind Redfern Grover Parkway siute 216/ 400 Rosalind Redfern Grover Parkway suite 271/ 07/15/2025 MQ: Called Aetna @ 800-353-1232 to obtain FU status of provider and spoke with Liz. Per rep provider is in network and linked effective 5/1/2023 under the grp/TIN. Next Re-cred is 5/1/2026. PIN:6669419. Loc is not on file. No request received. To add the loc, just send LOI along w/ W9 form via Fax# 8594558650 attn to Network Account Management. TAT is 30  bus days. Call ref#"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-01-15","This provider is already enrolled and active at Ste. 251, 261, and 271. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","","","2025-02-06","Provider is active under the ICR location effective 11/22/2024. PTAN 7F7404. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2025-08-12","For Locations:709 W Louisiana Ave/3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring\n/2402 W Wall/1805 S County Road 1105/5615 Deauville Blvd/4214 Andrews Hwy suite 107/400 Rosalind Redfern Grover Pkwy Suite 120\n/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/\n4214 Andrews Hwy Suite 103/4214 Andrews Hwy\tSuite 240/3423 Caldera Blvd\n/08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN. PIN is 3637790. Physical location is on file. Call ref# 1669742."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","2025-01-01","1922658319","","2025-09-18","Per TRICAREProviderInquiries@TriWest.com, our records indicate that the group Premier Family Care, Inc and the providers Venessa Saldana are credentialed effective on 01/01/2025. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR  with GRP and TIN effective 04/01/2025 for loc 4214 Andrews Hwy suite 103, 12/03/2024 for loc 4507   Santa Rosa Dr, 02/01/2025 for loc 400 Rosalind Redfern Grover Pkwy Suite 251,12/02/2024 for loc 3423   Caldera Blvd.  PIN is 3637790."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","1922658319","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","1922658319","","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-08-27","CAQH Profile/COI updated - next attestation due on 12/25/25. ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-08-27","CAQH Profile/COI updated - next attestation due on 12/25/25. ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-08-27","CAQH Profile/COI updated - next attestation due on 12/25/25. ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-08-27","CAQH Profile/COI updated - next attestation due on 12/25/25. ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-08-27","CAQH Profile/COI updated - next attestation due on 12/25/25. ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-08-27","CAQH Profile/COI updated - next attestation due on 12/25/25. ML"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025, PA."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4214 Andrews Hwy/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","6669419","","2025-08-12","For locations: 4507 Santa Rosa Dr/400 Rosalind Redfern Grover Pkwy 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-14","08/05/2025 MA: Provider is PAR with GRP and TIN effective 11/01/2022 for loc 4214 Andrews Hwy Suite 109, 02/01/2025 for loc 400 Rosalind Redfern Grover Parkway Suite 26, and 11/01/202271 for loc 400 Rosalind Redfern Grover Pkwy Suite 251. PIN is 3637790"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par  and linked to the group. eff date 6/6/2024For loc 3411  Caldera Blvd PIN: 441996207, 1805 S  County Road 1105 PIN:441996201, 2012 W  Ohio Ave PIN: 441996205. 2402 W Wall PIN:441996206, 3415 N Loop 250 PIN: 441996203, 3620 N Big Spring,400 Rosalind Redfern Grover Pkwy Suite 120 PIN:441996209,400  Rosalind Redfern Grover Pkwy  suite 200 PIN:441996210, 4214  Andrews Hwy Suite 107 suit 107 PIN: 441996211, 5615  Deauville Blvd PIN:441996212, 709 W   Louisiana Ave PIN:441996213, 400   Rosalind Redfern Grover Pkwy  suite 271 PIN-441996220. 4214   Andrews Hwy suite 103 PIN:441996215, 3423 Caldera Blv  Caldera Blvd PIN: 441996216\nCall ref# 51979348000"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-06-03","Rcvd practice locations update approval ltr. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2025-01-16","Revalidation approval ltr rcvd. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025, PA."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Ambetter","In Process","Re-Credentialing","","","","2024-12-11","Submitted via delegated roster. AS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2025-01-01","","","2025-01-06","Received Jan Validation report; provider is listed PAR., linked to TIN & location, eff. 1/1/2025, PA."]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-03-04","Unless updating the primary location, there is not notification needed for RR. Provider is already active under this TIN. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-06-01","8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring/2402 W Wall/5615 Deauville Blvd/4214 Andrews Hwy Suite 107/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 709 W Louisiana Ave/1805 S County Road 1105/4214 Andrews Hwy Suite 103/3423 Caldera Blvd 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is on file. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring/2402 W Wall/5615 Deauville Blvd/4214 Andrews Hwy Suite 107/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring/2402 W Wall/5615 Deauville Blvd/4214 Andrews Hwy Suite 107/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring/2402 W Wall/5615 Deauville Blvd/4214 Andrews Hwy Suite 107/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","6669419","","2025-08-12","For Locations: 3411 Caldera Blvd/3415 N Loop 250/3620 N Big Spring/2402 W Wall/5615 Deauville Blvd/4214 Andrews Hwy Suite 107/400 Rosalind Redfern Grover Pkwy Suite 120/400 Rosalind Redfern Grover Pkwy Suite 200/2012 W Ohio Ave/4214 Andrews Hwy Suite 240 08/04/2025 KN: Called Aetna@1-800-353-1232 and spk w/Jay. Per rep, provider is PAR under the Grp/TIN eff 11/15/2022. PIN 6669419. Physical location is not on file. Per rep, we can submit a request in writing through fax at Aetna Fax# 859-455-8650, ATTN: Demographic Team. Also include W9 Form. TAT is 30 buss days. Can cb on weekly basis for checking of status. Callref:255637771"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Provider Load","Provider Load","","","","2025-01-13",""]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Ana M Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01","403920802","","2024-06-13","Per TMHP license has been updated. Jen Videan"]
["Ana M Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-01","","","2020-10-09","10/9/2020 Confirmed provider is certified as a non-network provider with TriCare East. Kimberly Frazier"]
["Ana M Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-04-01","6891038","","2025-08-11","08/05/2025 MP: Called 1-800-353-1232 and spoke w Rald at Aetna. Stated provider is PAR with GRP and TIN effective 04/01/2021. PIN is 6891038. Loc on file. Call ref 256059921."]
["James D Richardson, MD","1306827266","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-11-06","6886462","","2023-12-19","S/W JasonG of Cigna @ 1-800-882-4462. Per rep, Provider is in network with Cigna for the state of TX and linked to the group and TIN# effective 11/06/2023. Next recredentialing date is on 11/01/2026. PIN: 6886462. Servicing location is on file. Payer# 62308. Call ref# JasonG12192023. - Willie Ravas"]
["James D Richardson, MD","1306827266","75-2656723","TX","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"]
["James D Richardson, MD","1306827266","75-2656723","TX","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"]
["Stephanie Denise Crawford, FNP","1265081616","27-4061759","TX","Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2022-12-19","","","2023-02-08","2/8/2023 Rcvd email from UHC that January delegated roster provider load has been completed and provider is PAR and linked to group TIN effective 12/19/2022.  MPIN# 007288273.  DCannon"]
["Stephanie Denise Crawford, FNP","1265081616","27-4061759","TX","Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2022-12-19","","","2023-08-31","8/31/2023 Per email from Marcus Wester at Humana January delegated roster has been completed and provider is PAR effective 12/19/2022.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Application Submitted","","","","2025-08-05","Submitted revalidation application 08/05/2025 req#20757489. MR"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1447882915","","2020-07-27","IMS complete"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","","First Health Coventry","Participating","Enrollment Complete","2024-10-01","3372421","","2025-03-04","Received confirmation via email from First Health, provider par as of 10/1/2024. FC"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2021-10-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 10/1/2020. KFrazier"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2020-08-12","1447882915","","2020-09-24","09/24/2020 - moved to completed status after reivewing follow up complete - Stacey Hudak"]
["Marlena Flores, CPNP","1215318092","75-2133441","TX","Midland Pediatric Associates, PLLC","IMS","In Process","Application Submitted","","","","2025-09-15","Application submitted via delegated roster. SG"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Enrollment Stopped","Enrollment Stopped","","","","2025-03-05","Location is now in TriWest territory and Tricare East enrollments are not longer valid per the Tricare rep. Enrollment and follow up will be documented on the TriWest HC Alliance payor lines. MS"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2025-04-01","","","2025-04-14","Location add request completed per SHP April validation report. PA."]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2023-11-01","","","2025-05-12","Received product roster from UHC; provider is linked to TIN/location, eff. 11/01/2023. PA."]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2018-02-28","1750796009","830358685","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","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"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","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","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","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","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2018-02-28","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 2/28/2018.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","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","Midland Community Healthcare Services","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-20","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2018-02-28","","","2020-06-04","06/04/2020 - Rec'd email from the payer stating this provider was EFF - Stacey Hudak"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2017-04-01","3016142","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 4/1/2017 PID # 3016142\ntisha rader"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","1447701602","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - stacey hudak"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","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"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-08","","","2021-12-14","12/14/2021 Per portal, provider linked to location as of 12/8/2021. Cbankston"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2018-01-01","1447701602","","2020-06-09","06/09/2020 - Rec'd email from the payer stating this provider is EFF 1-1-2018 under a DIRECT CONTRACT - Stacey Hudak"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","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."]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2016-07-26","","","2022-07-01","7/1/2022 Provider is PAR and linked to group TIN/location effective 7/26/2016.  DCannon"]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","Midland Community Healthcare Services","Rail Road Medicare","In House Enrollment","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","Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2015-08-29","","","2022-04-13","4/13/2022 Per roster from IMS/Omni provider is PAR and linked to group TIN/location effective 8/29/2015.  DCannon"]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2015-11-01","1154767234","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1154767234","","2020-09-02","09/02/2020 - rec'd email from the payer stating this updated has been completed - Stacey Hudak"]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2016-07-26","","","2021-07-01","7/1/2021 Received roster from Multiplan confirming participation of providers with TIN /locations effective 07/26/2016.  DCannon"]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","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"]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","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","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2019-05-03","","","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 5/3/2019.   DCannon"]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","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"]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2015-10-07","1154767234","","2020-06-30","6/30/2020 - Receved email spreadsheet from the paayor confirmg that this provider is EFF this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","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","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"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2019-03-15","1891931341","","2020-03-24","3/24/2020--Called Aetna @ 8008723862 but per rep, any inquiries about credentialing must call credentialing department @ 8003531232. Called 8003531232 and SW Ella, Per rep, Provider NPI# is on file and participating in-network under the group and TIN# effective 3/15/2019. Delegated contract under Permian Basin Healthcare. Location is on file. Call ref# 51992568633.\ntisha rader"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2015-05-20","","","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 5/20/2015.   DCannon"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","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","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","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","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","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"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","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, APRN-FNP-BC","1184265050","83-0358685","TX","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, APRN-FNP-BC","1184265050","83-0358685","TX","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, APRN-FNP-BC","1184265050","83-0358685","TX","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."]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-09","","","2022-02-10","2/10/2022 Per Tricare portal, provider is linked to location as of 12.9.2021. Cbankston"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","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, APRN-FNP-BC","1184265050","83-0358685","TX","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, APRN-FNP-BC","1184265050","83-0358685","TX","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"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","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"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","2022-11-15","Provider did not select inclusion with this payor."]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","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"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","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","ME","Midland Medicine PA","Aetna","Participating","Enrollment Complete","2021-09-01","6124960","","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 9/1/2021.  PID # 6124960 DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","ME","Midland Medicine PA","HealthSmart PPO","Participating","Enrollment Complete","2021-08-09","","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/9/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","ME","Midland Medicine PA","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"]
["Hagos Zeferu Aymut, MD","1922548890","47-5554737","TX","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"]
["Hagos Zeferu Aymut, MD","1922548890","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-07-15","1922548890","","2020-09-24","09/24/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Sep 9, 2020 8:14:13 AM. Your request was assigned reference number PR-5483219 .\"  - Stacey Hudak"]
["Hagos Zeferu Aymut, MD","1922548890","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-14","1/14/2021 - Rcvd email from payer that provider is participating and loaded under tax ID effective 9/28/2020.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","","","2025-06-23","Received confirmation via email from Mary Hanna, provider participating as of 10/7/2024. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","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"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2025-06-27","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 9/13/2024. PA."]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2020-04-10","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 04/10/2020. PA."]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","1528430865","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-12-01","3191800","","2023-09-20","09.20.2023 S/W ShannonD of First Health @ 800-226-5116 and transferred me over to Melanie. Per rep, the provider is in network with First Health for the state of TX and linked to the group and TIN# effective 12/01/2018. No next recredentialing date available. PIN: 3191800. Servicing location is on file. No payer# available. No call ref# available. - Willie Ravas"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","1528430865","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","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"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-12-03","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 12/03/2024. PA."]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","","Aetna","Participating","Enrollment Complete","2019-10-01","6875567","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of10/1/2019. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-07","","","2025-08-07","08/07/2025 CAQH Reattested-updated Cred Cont-dvineyard"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2023-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2023. PA."]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2018-11-20","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 11/20/2018.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2018-12-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","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"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","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","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1528430865","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2018 for all locations. PIN is the NPI."]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1528430865","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2018 for all locations. PIN is the NPI."]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","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","WesTex Urgent Care, PLLC","Zurich","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","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2019-10-01","6875567","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/1/2015. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2023. PA."]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","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","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1528430865","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2018 for all locations. PIN is the NPI."]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending Multiplan enrollment.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2025-02-04","Recceived confirmation via email from LaNetrice Myart, provider participating as of 9/13/2024. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-18","08/18/2025 AC: Called 800-882-4462 and spoke w Lysa at Cigna. Stated provider not PAR need to process over the phone for office based provider and for hospital based need to submit email through email at intake_pdm@evernorth.com. Call ref number Lysa T 08/18/2025"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-09-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 9/1/2024. FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-10","","","2024-07-01","Group record has been updated to show this location as active. No individual enrollment is required. MS"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete",""," 1215575576","","2024-08-13","Per TMHP, Jordan is enrolled and linked to Urgent Ortho Specialists effective 01/05/2020. Jen Videan"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-09-01","1215575576","","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"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2025-08-26","14594087","","2025-08-26","08/26/2025 CAQH Reattested-updated Cred Cont-dvineyard"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1215575576","","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"]
["Satish Nayak, MD","1518053149","57-1157825","TX","Satish Nayak","IMS","Participating","Enrollment Complete","2004-02-16","1518053149","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Satish Nayak, MD","1518053149","57-1157825","TX","Satish Nayak","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1518053149","","2020-06-10","06/10/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","ADA Adult and Children Family Clinic LLC","Cigna","Participating","Enrollment Complete","2019-09-01","9763901","","2020-06-22","06/22/2020 - Rec'd effective email from the payer - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","ADA Adult and Children Family Clinic LLC","USA PPO","Participating","Enrollment Complete","2023-07-01","","","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 7/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","ADA Adult and Children Family Clinic LLC","First Health Coventry","Participating","Enrollment Complete","2020-06-12","","","2023-10-09","10/9/2023 Rcvd email confirmation from Priscilla at MQA that provider effective date has been back dated to 6/12/2020 and the new location has been added.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","ADA Adult and Children Family Clinic LLC","First Health Coventry","Participating","Enrollment Complete","2020-06-12","","","2023-10-09","10/9/2023 Rcvd email confirmation from Priscilla at MQA that provider effective date has been back dated to 6/12/2020 and the new location has been added.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","ADA Adult and Children Family Clinic LLC","Medicare","Participating","Enrollment Complete","2020-03-30","1B0151","1B0142","2020-06-23","06/23/2020 - Rec'd PECOS login and was able to verify providers EFF info with group - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","ADA Adult and Children Family Clinic LLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-07-17","For Locations: 3416 W Wall St/ 2407 W Louisiana Ave 07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","ADA Adult and Children Family Clinic LLC","Medicaid","Participating","Enrollment Complete","2021-09-27","","","2023-12-01","NPI is a performing provider of the group for any location of the group. Dr. Okin-Ayileka does not need to be added as a performing provider for this location. Per Priscilla at TMHP the way the file is set up for ADA, Dr. Okin is considered a performing provider at any location of the group without having to add her to the individual locations. Jen Videan"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","Midland Texas Orthopedic Group Inc","Molina","Participating","Enrollment Complete","2021-03-12","","","2021-03-15","3/15/2021 Received forwarded email from Margaret.White@molinahealthcare.com confirming provider is now participating with network under group Tax ID with specialty of orthopedic surgery and orthopedic trauma effective 3/12/2021. KFrazier"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2025-09-05","","","2025-10-07","CAQH reattested. All information up to date. ML"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1538571609","","2024-06-28","Approval ltr rcvd. Provider eff 06/19/2024. Jen Videan"]
["Carlos Molina, DO","1225277833","75-1997880","TX","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.  Jen Videan"]
["Carlos Molina, DO","1225277833","26-3789190","TX","Permian Physician Services","Coventry Workers Comp","Participating","Enrollment Complete","2023-11-01","","","2024-02-01","Per Coventry portal provider is enrolled. Jen Videan"]
["Carlos Molina, DO","1225277833","75-1997880","TX","Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2017-03-18","1225277833","","2020-09-23","09/23/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Carlos Molina, DO","1225277833","75-1997880","TX","Andrews County Hospital District","Medicaid","Facility Enrollment","Facility Enrollment","","112273103","","2020-09-23","09/23/2020 - Rec'd email from the clinic with the group RHC TPI# 112273103.  Moved to effective status to bring payer line to a desired status. THIS IS A FACILITY ENROLLMENT - Stacey Hudak"]
["Carlos Molina, DO","1225277833","26-3789190","TX","Permian Physician Services","Liberty Mutual","Participating","Enrollment Complete","","","","2024-02-01","Per Coventry portal provider is enrolled. Jen Videan"]
["Carlos Molina, DO","1225277833","75-1997880","TX","Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2017-03-13","1225277833","","2020-07-15","07/15/2020 - Rec'd email from the payer stating this provider is EFF under this group TIN and group NPI# 1124054069 - Stacey Hudak"]
["Carlos Molina, DO","1225277833","75-1997880","TX","Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete","2024-05-21","1225277833","","2024-05-24","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["Carlos Molina, DO","1225277833","26-3789190","TX","Permian Physician Services","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-17","For Locations: 700 Hospital Drive/ 704 Hospital Drive 07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Margaret Merriam, DO","1083867147","26-3789190","TX","Permian Physician Services","Coventry Workers Comp","Participating","Enrollment Complete","2023-11-01","","","2024-02-01","Per Coventry portal provider is enrolled. Jen Videan"]
["Margaret Merriam, DO","1083867147","26-3789190","TX","Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2017-10-23","1083867147","","2020-08-19","8/19/2020 - Rec'd email from the payer stating this provider is already affiliated with the PRIMED DELEGATED AGREEMENT and enrolled with this group TIN/Service Location and group NPI# 1124054069 - Stacey Hudak\n\n**Verified 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"]
["Margaret Merriam, DO","1083867147","75-1997880","TX","Andrews County Hospital District","Travelers WC","Participating","Enrollment Complete","","","","2023-05-29","Per Coventry portal provider is enrolled. Jen Videan"]
["Margaret Merriam, DO","1083867147","75-1997880","TX","Andrews County Hospital District","Superior","Participating","Enrollment Complete","2017-07-01","1083867147","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Margaret Merriam, DO","1083867147","75-1997880","TX","Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-08-05","04727806","","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"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","Permian Physician Services","Medicare","Participating","Enrollment Complete","2021-01-01","1M9244","","2021-04-26","4/26/2021 Per Stacy Salazar she processed provider's enrollment application and assigned PTAN is 1M9244, effective 1/1/2021. KFrazier"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","Permian Physician Services","Aetna","Participating","Enrollment Complete","2020-09-16","9363366","","2025-08-11","08.05.2025 MG: Called Aetna @ 1-800-353-1232 to obtain PNP/FU status for the provider and spoke to Kristen. Per rep, NPI# is on file for the provider and is participating  under the group and TIN#. Physical location is on file. Provider ID is 9363366. Call ref# 256064729."]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","2019-05-03"," 1669617981","","2021-12-27","12/27/2021 Received email form michelle.killough@pswca.org, provider has been active with Tax ID  75-1997880 since 05/03/2019. Cbankston"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","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","26-3789190","TX","Permian Physician Services","USA PPO","Participating","Enrollment Complete","2019-08-30","1138545","","2020-12-17","12/17/2020 Per provider roster from September provider is listed as par at this location effective 8/30/2019.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2015-10-29","01449153","","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 3/1/2012; Medicare - eff 8/1/2012; C-SNP - eff 1/1/2017; Other - eff 1/1/2021, Plus - eff 3/1/2012, Star_Kids - eff 11/1/2016.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","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"]
["Shannan Clawson, NP","1972073906","75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2022-03-02","","","2022-04-18","4/18/2022 Per Tricare portal, provider is par as of 3.2.2022. Cbankston"]
["Shannan Clawson, NP","1972073906","75-1997880","TX","Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2020-08-05","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/5/2020.  DCannon"]
["Shannan Clawson, NP","1972073906","75-1997880","TX","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"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Re-Credentialing","2021-05-10","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Barbara Norris, NP-C","1720353592","75-1997880","TX","Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2014-05-15","","","2020-09-14",""]
["Barbara Norris, NP-C","1720353592","75-1997880","TX","Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2016-01-01","1720353592","","2020-08-04","8/4/2020 - Rec'd email from the payer stating this provider is EFF with this group NPI# for Quick Care under the Delegated Agreement - Stacey Hudak\n\n**verified that this provider is networked with:\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Stephanie Jean Fitzgerald, MD","1184035313","26-3789190","TX","Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2020-08-05","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 8/5/2020.  DCannon"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","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","Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2020-06-22","","","2020-10-27","10/27/2020 Confirmed provider is certified as a non-network provider. Kimberly Frazier"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2025-09-15","","","2025-09-15","09/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Stephanie Jean Fitzgerald, MD","1184035313","26-3789190","TX","Permian Physician Services","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-17","For Locations: 700 Hospital Drive/704 Hospital Drive 07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Stephanie Jean Fitzgerald, MD","1184035313","26-3789190","TX","Permian Physician Services","Alliance WC","Participating","Enrollment Complete","2020-12-04","1184035313","","2023-05-22","Michelle Killough confirmed provider is effective 12/4/2020. MS"]
["Cynthia A Hill, CNS","1225271224","75-1997880","TX","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","Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-02","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Rahul Dinesh Puri, MD","1306928098","75-1997880","TX","Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2017-07-26","1306928098","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rahul Dinesh Puri, MD","1306928098","75-1997880","TX","","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","26-3789190","TX","Permian Physician 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"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","Permian Physician Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-06-01","6/1/2021 Revalidation required mailing of original, which Chris Dalllaire of practice mailed directly to payor and forwarded us a signed copy for our files. KFrazier"]
["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","","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-17","For Locations:700 Hospital Dr/704 Hospital Drive 07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Rahul Dinesh Puri, MD","1306928098","75-1997880","TX","Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2016-03-30","1306928098","","2020-08-04","8/4/2020 - Rec'd email from the payer confirming this provider is enrolled/linked to this group NPI - Stacey Hudak\n\n8/20/2020 - Rec'd a spreadsheet from the payer stating this provider is affilaited with the PRIMED DELEGATED ROSTER 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"]
["Rahul Dinesh Puri, MD","1306928098","75-1997880","TX","","Amerigroup","Participating","Enrollment Complete","2020-07-14","03829159","","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"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","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","Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete","2024-05-21","1306928098","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 3/16/2016.  DCannon"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","","Sedgwick","Participating","Enrollment Complete","2024-05-21","1306928098","","2024-05-22","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["Paul Slaughter, DO","1184626749","75-1997880","TX","Andrews County Hospital District","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Paul Slaughter, DO","1184626749","75-1997880","TX","Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-07-13","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 7/13/2020.  DCannon"]
["Paul Slaughter, DO","1184626749","75-1997880","TX","Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2009-04-01","1184626749","","2020-07-20","07/20/2020 - moved to completed status after reviewing follow up complete note. Provider has a DELEGATED agreement - Stacey Hudak"]
["Maria Montero, MD","1508218843","75-2656723","TX","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","North Big Spring Family Care","Cigna","Participating","Enrollment Complete","2021-02-02","1181373","","2021-02-22","2/17/2021 - Rcvd confirmation email from CIGNA that provider is participating effective 2/2/2021 PIN 1181373.  DCannon"]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","Andrews County Hospital District","Medicaid","Participating","Enrollment Complete","2013-12-25","330329902","324676102","2020-10-23","10/23/2020 - Rec'd TMHP enrollment approval letter from the clinic - Stacey Hudak"]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","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"]
["Lindsay M Friesenhahn, PA","1558979013","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2024-10-07","","","2025-01-07","Provider participating as of 10/7/2024 via roster. FC"]
["Lindsay M Friesenhahn, PA","1558979013","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-04","Panel is closed to new enrollments/locations. MS"]
["Lindsay M Friesenhahn, PA","1558979013","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-12-16","","","2025-08-12","08/04/2025 KC: Called 1-800-353-1232 and spoke w Frances M at Aetna. Stated provider is innetwork and link to the tax id effective 12/16/2024.Provider id# 8557269.Physical location is onfile.Call ref# 255600156.Called again Aetna and spoke w/ Liz P per rep aetna payer # is 60054.Call ref 255654594"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-05-01","9212791","","2021-05-07","5/7/2021 Called Aetna (888-632-3862 spoke with Andrea (call ref # 6017548190) she informed me that provider is PAR and linked to TIN/location effective 4/1/2021 PID 9212791.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-04-01","9212791","","2021-05-07","5/7/2021 Called Aetna (888-632-3862 spoke with Andrea (call ref # 6017548190) she informed me that provider is PAR and linked to TIN/location effective 4/1/2021 PID 9212791.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2020-09-17","","","2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-01","","","2025-05-12","Received product roster from UHC; provider is linked to TIN/location, eff. 11/01/2023. PA."]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-09-17","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-09-17","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","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"]
["Ni Adams, APRN-NP","1194355339","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Application Submitted","2024-02-27","","","2025-08-12","Submitted the revalidation for Medicaid. Request # is 20764881. 8/12/25 VA"]
["Ni Adams, APRN-NP","1194355339","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-12-01","","","2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Ni Adams, APRN-NP","1194355339","75-2656723","TX","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."]
["Rachel Ann Murphy, RD","1124637160","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-12-07","","","2021-01-06","1/6/2020 - Rcvd confirmation from payor that provider load is complete.  DCannon"]
["Eliana Kelley, APRN-FNP-BC","1184278251","75-1997880","TX","Andrews County Hospital District","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Eliana Kelley, APRN-FNP-BC","1184278251","75-1997880","TX","Andrews County Hospital District","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","Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2025-09-23","","","2025-09-23","09/23/2025 CAQH Reattested-updated Cred Cont-dvineyard"]
["Eliana Kelley, APRN-FNP-BC","1184278251","75-1997880","TX","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"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2022-08-18","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2021-01-13","","","2021-05-04","5/4/2021 Upon review of email response and roster received from networkhelp@uhc.com, provider is participating with Commercial Choice, Community & State, and Medicare under group Tax ID effective 1/13/2021. KFrazier"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","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","","Aetna","Participating","Enrollment Complete","2023-06-15","6761851","","2023-12-27","12/27/23 Per Follow-Up note - Provider is in network with Aetna for the state of TX and linked to the group and TIN# effective 06/15/2023. No next recredentialing date available. PIN: 6761851. Servicing location is on file. DCannon"]
["Daniel J Dominguez, APRN-FNP-BC","1720610447","74-2348334","TX","Permian Gastroenterology PA","Humana","Participating","Enrollment Complete","2023-07-17","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 07/17/2023. PA"]
["Daniel J Dominguez, APRN-FNP-BC","1720610447","74-2348334","TX","","Humana","Participating","Add Info Submitted","2023-07-17","","","2025-03-14","Submitted the group's request to remove provider from Humana Medicare LOB only via delegated roster. PA."]
["Meagan Leighann Cunningham, APRN-FNP-BC","1891302931","75-1997880","TX","Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-07","1312391","","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"]
["Meagan Leighann Cunningham, APRN-FNP-BC","1891302931","75-1997880","TX","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."]
["Bola O Jaiyeola, NP","1235605064","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2025-09-01","","","2025-09-08","Per the September SHP Validation report, provider is enrolled, linked to TIN/location, eff. 9/1/2025.  ML"]
["Bola O Jaiyeola, NP","1235605064","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-02-08","","","2025-09-24","Received email notification from Marcus Wester (mwester@humana.com) confirming provider's participation with network under new TIN/Location. ML"]
["Bola O Jaiyeola, NP","1235605064","47-5554737","TX","","CAQH","Participating","CAQH Reattested","2025-08-26","","","2025-07-18","CAQH Reattestation completed on 7/18/25 by another user. Next attestation due on 11/15/25. ML"]
["Bola O Jaiyeola, NP","1235605064","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Active","Payor Follow Up","2021-02-08","","","2025-06-05","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Bola O Jaiyeola, NP","1235605064","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","In Process","Add Info Submitted","","","","2025-09-17","Sent Emily Starr Lee Kinard and Aleece Moerbe an email requesting network status. SG"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-01-06","","","2025-03-24","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 01/06/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1861504987","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St/ 6301 Andrews Hwy/ 3490 E Yukon Rd./  Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-02-21","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 2/21/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-02-21","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 2/21/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-01-01","7F4080","423838","2025-02-03","Provider has been added to the group record. MS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-01-01","7F4080","423838","2025-05-01","Provider is linked to both group TIN's. MS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-01-01","Q00961273","DX4335","2025-02-20","Confirmed enrollment. MS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2025-03-01","","","2025-08-27","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 3/1/2025 for all locations. PIN is the NPI."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 AC: For location: 616 N Main St/ 4705 Briarwood Ave/ 6301 Andrews Hwy/ 6950 Eastridge Rd./ 3490 E Yukon Rd./ 5514 N Big Spring St Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-01-15","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 1/15/2025. FC"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-01-15","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 1/15/2025. FC"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-04-16","1861504987","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 4/16/2025 for all locations. NPI# is PIN."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-04-16","1861504987","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 4/16/2025 for all locations. NPI# is PIN."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-01-06","","","2025-03-24","Received email confirmation provider is PAR, linked to TIN/location, eff. 1/6/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2008-11-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 11/1/2008. FC"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-02-21","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 2/21/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-02-21","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 2/21/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-01-06","","","2025-01-28","Received confirmation via email from Emily Starr that provider is participating. AS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-01-06","","","2025-01-28","Received confirmation via email from Emily Starr that provider is participating. AS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-02-06","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/locations, eff. 02/06/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-30","Received confirmation via email from TexasNetwork@LibertyMutual.com, provider participating eff date 7/1/2025. FC"]
["Ernest J Buck, MD","1861504987","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-02-27","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Ernest J Buck, MD","1861504987","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-01-15","","","2025-01-31","Received confirmation via email from Angela Bates, provider participating as of 1/15/2025 with Blue Choice PPO, Blue Advantage HMO, Blue Essentials HMO, Health Select, Medicare Advantage PPO. FC"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Ernest J Buck, MD","1861504987","47-3465832","tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Ernest J Buck, MD","1861504987","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-01-06","","","2025-04-14","Received email from Karen Avalos confirming January roster was processed. Provider par, eff. 01/06/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-01-06","","","2025-04-14","Received email from Karen Avalos confirming January roster was processed. Provider par, eff. 01/06/2025. PA."]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-06","","","2025-08-06","08/06/2025 CAQH Reattested-updated TX Lic exp and uploaded doc and updated Cred Cont-dvineyard"]
["Amanda Compton, MD","1679953517","75-1997880","TX","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"]
["Amanda Compton, MD","1679953517","26-3789190","TX","Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2022-12-01","","","2023-03-08","3/8/2023  Per email from Karen Avalos at Galaxy delegated roster for December is complete and provider is loaded effective 12/1/2022.  DCannon"]
["Amanda Compton, MD","1679953517","26-3789190","TX","Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-12-01","","","2023-02-28","2/28/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Superior that provider is PAR and linked to group TIN/location effective 12/1/2022.  DCannon"]
["Amanda Compton, MD","1679953517","26-3789190","TX","Permian Physician Services","Caprock (CapStar)","Participating","Re-Credentialing","2022-12-01","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD","1679953517","75-1997880","TX","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","26-3789190","TX","Permian Physician Services","IMS","Participating","Re-Credentialing","2022-12-01","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD","1679953517","26-3789190","TX","Permian Physician Services","Cigna","Participating","Enrollment Complete","2022-12-01","2149846","","2023-01-31","1/31/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 12/1/2022.  PID # 2149846.  DCannon"]
["Karthik Chakrala, DO","1043633233","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing","2021-05-10","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Karthik Chakrala, DO","1043633233","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-06-08","1147058","","2021-07-06","7/2/2021 Received email from PDMCOGZ@Cigna.com confirming provider is now participating under group Tax ID effective 6/8/2021 with provider ID 1147058. KFrazier"]
["Karthik Chakrala, DO","1043633233","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2021-06-01","","","2021-06-03","6/3/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 6/1/2021.  DCannon"]
["Karthik Chakrala, DO","1043633233","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Re-Credentialing","2021-05-10","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin M Moose, APRN-FNP-BC","1215213970","75-2182177","TX","Debbie P. Reese, MD PA","BCBSTX","Participating","Confirm Par Status","2023-04-07","","","2024-06-18","Per BCBSTX rep Angelica Johnson, provider is PAR, linked to TIN/location, eff. 04/1/2023. PA"]
["Kristin M Moose, APRN-FNP-BC","1215213970","75-2182177","TX","Debbie P. Reese, MD PA","Omni PPO","Participating","Re-Credentialing","2023-12-11","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Emily N Baker Butler, DO","1053817940","75-2656723","TX","","IMS","Participating","Application Resubmitted","2021-08-09","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Emily N Baker Butler, DO","1053817940","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Emily N Baker Butler, DO","1053817940","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-10-02","Confirmed this was updated. MS"]
["Emily N Baker Butler, DO","1053817940","75-2656723","TX","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 N Baker Butler, DO","1053817940","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted","2021-08-09","","","2024-04-19","4/19/2024- Submitted new last name via delegated roster on 4/15/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-12-20",""]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1851865067","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","6764944","","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","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2021-10-08","1851865067","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 10/08/2021.  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"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",""," 1851865067","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2021 for all locations. PIN is the NPI."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-07-24","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 07/24/2024. PA."]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","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","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-10-16","No updates are needed for RR MCR when adding a new location unless that location will be updated to the primary location. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Application Submitted","2024-08-31","","","2024-09-30","As per Cassandra Dunagon submit application via delegated roster. Submitted delegated roster on 9/30/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2022-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 1/01/2022. PA."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2021-10-08","1851865067","","2024-02-15","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-07-01","","","2024-06-28","Group enrollment has been approved and this location has been linked and is active effective 7/1/2024. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1851865067","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2021 for all locations. PIN is the NPI."]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1851865067","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2021 for all locations. PIN is the NPI."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2024-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-07-01","","","2024-05-31","Facility Enrollment. Providers services are billed through the facility, not an individual claim. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-07-01","","","2025-08-13","08/05/2025 AB: Called Cigna @ 800-882-4462 to obtain PNP/FU status for the provider and spoke to Aby S. Per rep, Provider is INN and link to GRP and TIN, eff 7/1/2024. PIN 5731972. Physical Location is on file. Call Ref#AbyS08052025."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-29","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-12-07","","","2025-08-13","For Locations: 4705 Briarwood Ave/ 6950 Eastridge Rd. 08/05/2025 AB: Called Cigna @ 800-882-4462 to obtain PNP/FU status for the provider and spoke to Aby S. Per rep, Provider is INN and link to GRP and TIN, eff 12/7/2023. PIN 5731972. Physical Location is on file. Call Ref#AbyS08052025."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-12-07","","","2025-08-13","08/05/2025 AB: Called Cigna @ 800-882-4462 to obtain PNP/FU status for the provider and spoke to Aby S. Per rep, Provider is INN and link to GRP and TIN, eff 12/7/2023. PIN 5731972. Physical Location is on file. Call Ref#AbyS08052025."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","","Omni PPO","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","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","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2021-11-13","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 11/13/2021. PA."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-10","","","2024-07-01","location has been added to the group record and no ind. enrollment is required. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","3578768","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-08-12","08/12/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 09/01/2021. PA."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-12-06","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-12-03","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 12/03/2024. PA."]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","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"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-04-18","1851865067","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 4/17/2024 for all locations. NPI# is PIN."]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Application Resubmitted","2023-10-02","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","Omni PPO","Participating","Enrollment Complete","2023-01-03","","","2023-05-17","5/17//2023 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-01-03","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","Boon Chapman","Participating","Enrollment Complete","2021-08-13","","","2023-08-21","8/21/2023 Provider PAR w/ Multiplan effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-01-03","","","2023-11-13","11/13/2023 Per phone conversation w/ Lee Kinard at Healthsmart provider is PAR and linked to group TIN effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","HealthSmart PPO","Participating","Application Resubmitted","2023-01-03","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Neil P Doctor, MD","1619322492","92-0763047","TX","VYVO Therapeutics","Cigna","Participating","Enrollment Complete","2023-12-14","4110850","","2025-08-11","08.05.2025 MG: Called Cigna @ 1-800-882-4462 to obtain PNP/FU status for the provider and spoke to Ron. Per rep, NPI# is on file for the provider and is participating under the group and TIN# but no eff date provided since it's based on the loc. Physical location is not on file/not matching on their system. To add/update loc, send an email to intake_pdm@evernorth.com with the tax id, name of the provider, new addresses, and attach w9 form. TAT 20-30 CD. Provider ID is 4110850. Call ref# Ron P. 08/05/2025."]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","","","2024-04-29","Provider is approved and linked to this location eff 7/20/2022. MS"]
["Addis Getahun, MD","1548765183","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Add Info Submitted","2021-11-01","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Addis Getahun, MD","1548765183","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-11-01","","","2021-12-30","12/30/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 11/1/2021.  DCannon"]
["Addis Getahun, MD","1548765183","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2022-04-05","","","2022-04-21","4/21/2022 Per email received from Ryan Gardner at Multiplan provider is PAR and linked to group/location effective 4/5/2022.  DCannon"]
["Addis Getahun, MD","1548765183","47-5554737","TX","","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","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 3630197, Payer ID 73159 and Recredentialing date 12/01/2025. Service location is on file. Call ref#:517681. -Danico Gabriel Melendres"]
["Addis Getahun, MD","1548765183","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Add Info Submitted","2023-09-01","3733859","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Martha Denise Mourning, NP","1922552959","75-2656723","TX","","USA PPO","Participating","Payor Follow Up","2025-09-01","","","2025-08-15","Requested enrollment status via email, sent to payor. ML"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","","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","Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Add Info Submitted","2021-10-29","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","","Multiplan","Participating","Add Info Submitted","2021-12-22","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","","HealthSmart PPO","Participating","Add Info Submitted","2021-10-29","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2021-09-27","6663751","","2022-06-22","6/22/2022 Per email received from UHC with a roster attached provider is PAR and linked to group TIN/locations effective 9/27/2021.  MPIN # 6663751.  DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-11-18","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 11/18/2021.  DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2021-10-12","1V0903","519061","2021-10-07","10/7/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN # 1V0903 - effective 10/12/2021.  DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","","HealthSmart PPO","Participating","Enrollment Complete","2021-11-18","13800916","","2022-04-23","4/23/2022 Per follow-up note - Provider's NPI is on file and participating under the group and TIN# effective 11/18/2021.  Physical location is on file.  Provider ID is 13800916.   DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","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"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2021-11-18","","","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 11/18/2021.  DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","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"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2024-08-19","As per Cassandra Dunagon received confirmation provider participating as of 5/1/2023 via email. FC"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2023-11-03","1912482209","","2023-11-20","Rcvd approval ltr. Provider effective 11/03/2023. Jen Videan"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","Urgent Orthopedic Specialists, 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"]
["Judy J Jia, MD","1588983134","75-2656723","TX","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"]
["Judy J Jia, MD","1588983134","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."]
["Judy J Jia, MD","1588983134","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Judy J Jia, MD","1588983134","75-2656723","TX","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"]
["Judy J Jia, MD","1588983134","75-2656723","TX","","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","","United Health Care","Participating","Enrollment Complete","2022-04-11","006052910","","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 4/11/2022.   MPIN# 006052910.   DCannon"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","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"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-09-24","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-03-02","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 3/10/2022.  DCannon"]
["John H Ownby, MD","1558343988","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["John H Ownby, MD","1558343988","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["John H Ownby, MD","1558343988","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01","2359722","","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# 2359722  DCannon"]
["John H Ownby, MD","1558343988","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"]
["John H Ownby, MD","1558343988","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11","002074110","","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 4/11/2022.   MPIN# 002074110.   DCannon"]
["Elena Krendelshchikova, APRN-NP","1356714406","27-4061759","TX","Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2024-08-05","","","2024-10-04","Received confirmation via email from Geman Aviles, provider participating as of 8/5/2024. FC"]
["Elena Krendelshchikova, APRN-NP","1356714406","27-4061759","TX","Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2022-05-13","6105828","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 05/13/2022.  PA"]
["Elena Krendelshchikova, APRN-NP","1356714406","27-4061759","TX","Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2024-08-05","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  08/05/2024.  PA."]
["Megan E Rosa, PA","1720698640","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2024-10-07","","","2025-01-07","Provider participating as of 10/7/2024 via roster. FC"]
["Megan E Rosa, PA","1720698640","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-11-06","Received confirmation via phone call from German Aviles. Provider participating as of 10/7/2024. FC"]
["Megan E Rosa, PA","1720698640","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-10-07","","","2025-01-29","Received confirmation via email from Caprock rep, provider participating as of 10/7/2024. FC"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Re-Credentialing","2022-07-01","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-09-03","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 9/3/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2022-07-01","","","2022-10-17","10/17/2022 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 7/1/2022.   DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","","","2024-09-04","Confirmed via portal, provider is linked and active. MS"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-07-01","","","2023-07-11","Received confirmation from Client. MS"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","","","","2024-01-26","TIN is delegated. Confirmed enrollment via Coventry Portal. MS"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2022-04-14","","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 4/14/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Confirm Par Status","2022-05-09","","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of  05/09/2022. PA."]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-26","TIN is delegated. Confirmed enrollment via Coventry Portal. MS"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Confirm Par Status","2022-04-14","","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of 04/14/2022.  PA."]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-26","Confirmed via Coventry Portal. MS"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","","","","2024-01-26","Confirmed via Coventry Portal. MS"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2022-05-09","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2022-08-08","9392106","","2022-09-27","9/27/2022 Per follow-up note - S/W Sophie of Cigna @ 1-800-882-4462. NPI# is on file for the provider and is participating effective 08/08/2022 under the group and TIN. Provider ID# 9392106. Physical location is on file.  DCannon"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","","Amerigroup","Participating","Re-Credentialing","2022-05-09","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","","Aetna","Participating","Re-Credentialing","2022-05-09","6227554","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","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","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","Midland Community Healthcare Services","United Health Care","Participating","Add Info Submitted","2022-05-09","007929415","","2025-07-15","Submitted request to update phone/fax #'s for each location via delegated roster submission. PA."]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","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","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","Midland Community Healthcare Services","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"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","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","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","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","Midland Community Healthcare Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-26",""]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","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","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","Midland Community Healthcare Services","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","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","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","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","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","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","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","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","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","Premier Texas Kidney Care, PLLC","Superior","Participating","Add Info Submitted","2022-08-01","","","2025-07-15","Submitted primary practice and mailing address update (1809 Middleton St) to payor per request. PA."]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","Premier Texas Kidney Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","2022-06-20","","","2025-06-05","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Sridhar R Allam, MD","1700061819","","TX","","Aetna Better Health","Participating","Enrollment Complete","2025-04-24","","","2025-06-23","Received email confirmation provider is now PAR, linked to TIN/location, eff. 04/24/025. PA."]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","Premier Texas Kidney Care, PLLC","Medicaid","Participating","Enrollment Complete","2022-05-01","","","2024-01-31","Provider was added during group enrollment. Provider is active with Medicaid, effective 05/01/2022. Jen Videan"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","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"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-08-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/15/2022.  DCannon"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","003315195","","2022-11-01","11/1/2022 Rcvd email from UCH that provider load has been completed and provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-06-20","","","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 6/20/2022.  DCannon"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","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"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025. Provider is enrolled in Ambetter (Commercial-EXchange). ML"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Location effective 7/8/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2025-03-05","7L8643","","2025-06-25","Per PECOS provider is active and linked to group. Effective 03/05/2025. PTAN: 7L8643. Jen Videan"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","CAQH","Participating","CAQH Reattested","2025-08-07","","","2025-08-27","CAQH Profile/ COI Updated - next attestation due on 12/25/25. ML"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","Humana","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation of provider enrollment effective 7/8/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","Healing Hands Medical Clinic","USA PPO","Participating","Enrollment Complete","2022-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","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."]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","Healing Hands Medical Clinic","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"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","2023-06-02","1598260325","","2023-06-09","confirmed via the website directory the provider is active. MS"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2022-11-01","","","2023-02-09","2/9/2023 Rcvd email from Priscilla Albertine at MQA with confirmation that provider is PAR and linked to group TIN/location effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","Permian Physician Services","Aetna","Participating","Enrollment Complete","2023-01-01","","","2025-08-12","08.05.2025 JJ: Called Aetna @ 1-800-353-1232 to obtain FU status of the provider and s/w Vince. Per rep, provider is in-network and linked to TIN for the state of TX with eff date 01/15/2023. PIN: 6836243. Physical location is on file. Call ref#: 256068217."]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","Permian Physician Services","CAQH","Participating","CAQH Reattested","2025-08-20","","","2025-08-20","08/20/2025 CAQH Reattested-updated COI and uploaded doc-dvineyard"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete","2024-05-21","1598260325","","2024-05-24","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","Andrews County Hospital District","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"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","Andrews County Hospital District","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"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-03-01","","","2023-08-31","8/31/2023 Per email from Marcus Wester at Humana January delegated roster has been completed and provider is PAR effective 3/1/2023.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-07-08","","","2024-10-31","Approval ltr has been rcvd. Location has been added to provider's profile effective 07/08/2023. Jen Videan"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2022-11-28","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2022-11-28","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","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","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","Midland Community Healthcare Services","Wellcare","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","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-10-06","5935530","","2023-09-21","09.21.2023 S/W Dennisse of Cigna @ 1-800-882-4462. Per rep, provider is part of a behavioral program then rep advised to call the behavioral dept at 800-274-4573. Called Cigna's behavioral dept @ 800-274-4573 then S/W Heba. As per rep, provider is showing participating and link under the Group and TIN with an Effective date 02/02/2023. Provider ID 5935530. Service location is on file. Call ref#:HebaH09212023. - Danico Gabriel Melendres"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-03-13","","","2023-03-28","3/28/2023 Rcvd Tricare certified approval letter.   Provider is TRICARE-certified in Texas effective  3/13/2023.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","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","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-10-31","","","2022-12-29","12/29/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","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","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","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","Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-10-31","","","2023-01-05","1/5/2023 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","Midland Community Healthcare Services","TriWest HC Alliance","Participating","Payor Follow Up","2022-10-31","","","2025-07-18","For Locations: 400 Rosalind Redfern Grover Pkwy/801 E Florida Ave/4214 Andrews Hwy/401 E Illinois Ave 07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","Participating","Payor Follow Up","2022-10-31","","","2025-07-18","For Locations: 400 Rosalind Redfern Grover Pkwy/801 E Florida Ave/4214 Andrews Hwy/401 E Illinois Ave 07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Marisela Sample, LPC","1396470357","83-0358685","TX","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","Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2022-10-04",""]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-24","Tricare Prime panel is closed. MS"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-10-31","008256523","","2023-09-05","9/5/2023 Per follow-up email from UHC provider is PAR and linked to group/location effective 10/31/2022.  MPIN#  008256523\n DCannon"]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","Debbie P. Reese, MD PA","First Health Coventry","Participating","Enrollment Complete","2024-01-01","","","2024-06-25","As per Teresita (call ref# 1105034) Andrews Highway location is active with FirstHealth. FC"]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","Debbie P. Reese, MD PA","Humana","Participating","Enrollment Complete","2023-02-06","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  2/062023.  PA."]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Thru Other Payor","Thru Other Payor","2024-03-01","","","2024-05-22","Pending Multiplan enrollment. PA."]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2024-02-10","Q00724982","","2024-04-25","Received confirmation of enrollment. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-08-25","8/25/2023 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"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-08-25","8/25/2023 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"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-06-09","1538714076","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-21","","","2025-08-21","08/21/2025 CAQH Reattested-updated TX Lic exp and uploaded doc-dvineyard"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-05-01","","","2024-05-09","Received email from Marina Martinez of USA MCO, provider is PAR and 616 Main St location linked, eff. 05/01/2024."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","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","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","","IMS","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","Tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n6301 Andrews Hwy 5/6/2024\n616 N Main St & 4705 Briarwood Ave eff. 6/12/2023. AS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-01","","","2023-09-26","Confirmed provider is loaded at the Briarwood location effective 9/1/23. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","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","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-12-03","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 12/03/2024. PA."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-06-09","1538714076","","2024-11-14","Please see status updates under Alliance WC payor line. Jen Videan"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-14","","","2024-07-19","Received roster from HP Delegation; provider is shown linked to TIN/locations, eff. 05/14/2023. PA."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","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"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-03-17","Q00521373","","2023-07-27","7/27/2023 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group effective 3/17/2023. PID # Q00521373.  DCannon"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","tx","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-03-17","Q00521373","","2023-07-27","7/27/2023 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group effective 3/17/2023. PID # Q00521373.  DCannon"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-14","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 05/14/2023. PA."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","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","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","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","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-06-09","1538714076","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1538714076","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 8/1/2023 for all locations. PIN is the NPI."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-06-26","00726107","","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","WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","Tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","Tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","Permian Physician Services","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-07-18","07/17/2025 AC: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","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","Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-08","","","2023-05-22","5/22/2023 Rcvd email from Caprock that May roster has been processed and provider is PAR w/ group effective 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","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"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","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","","PPHP","Participating","Enrollment Complete","2023-06-01","","","2025-05-27","Received email from Keandra W. confirming  April roster has been processed. Provider is par, linked to TIN/location, eff 6/1/2023. PA."]
["David Powell Haynie, MD","1083672778","75-2656723","TX","","Aetna","Participating","Enrollment Complete","2023-05-01","","","2025-08-11","08.05.2025 MG: Called Aetna @ 1-800-353-1232 to obtain PNP/FU status for the provider and spoke to Moana. Per rep, NPI# is on file for the provider and is participating effective 05/01/2023 under the group and TIN#. Physical location is on file. Provider ID is 4135209. Call ref# 256049998."]
["David Powell Haynie, MD","1083672778","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2W8694","","2023-08-01","Received enrollment completed email effective 5/1/2023. \nApplication Tracking ID: T071820230002417\n NPI ID: 1083672778\n Medicare ID: 2W8694\n Name: DAVID HAYNIE\n State: TX\n Form Type: 855I\n Date: 08/01/2023\n Status: APPROVED"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2024-12-13","","","2025-07-16","Received email from LaNetrice Myart confirming provider is participating, linked to TIN/location, eff. 12/13/2024. PA."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","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","WesTex Urgent Care, PLLC","Aetna","Participating","Application Resubmitted","2023-04-14","9695700","","2024-09-27"," Unable to get confirmation from Brandy or Hannah if the requested termination would be stopped. I submitted application via delegated roster on 9/27/2024. FC"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","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","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-01-24","Re-Cred application approved. MS"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-01-24","Re-Cred application approved. MS"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-17","Received email confirmation from PPHP, provider is linked to the location/TIN, eff. 7/11/2024. PA."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-01","9695700","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 6/1/2023. FC"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","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"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","","First Health Coventry","Participating","Enrollment Complete","2023-06-01","2243378","","2023-10-26","10/26/2023 S/W Bridgette 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 location is on file. Call ref#:754015. - DCannon"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-06-01","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 06/01/2023, and linked to 616 Main St. location. PA."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-08-25","1518292077","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 07/20/2023. PA."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-29","","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","In House Enrollment","2024-05-29","","","2025-01-14","1/14/2025- Per Priscilla email - Provider Maintains CAQH"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-29","","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from\nTexas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-29","","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from\nTexas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-06-10","","","2023-09-21",""]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","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","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-08-19","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, linked to TIN and Location , effective 08/19/2023.  PA"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","1518292077","","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","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-05-07","7L0326","6P6053","2025-04-16","Confirmed the provider is linked to this PTAN. MS"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. MS"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-09-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd 5/21/2024\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 9/1/2024\n616 N Main st eff. 6/12/2023. AS"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-09-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd 5/21/2024\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 9/1/2024\n616 N Main st eff. 6/12/2023. AS"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","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","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-06-12","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 wxcept Longview location. FC"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-06-12","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 wxcept Longview location. FC"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-07-01","","","2025-06-24",""]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","1518292077","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 8/21/2024 for all locations. NPI# is PIN."]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-08-04",""]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","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"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-06-12","","","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 6/12/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2025-08-26","13954674","","2025-08-26","08/26/2025 CAQH Reattested-updated Cred Cont-dvineyard"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","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","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","West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2023-06-22","1073983193","","2024-11-19","Received confirmation of Triwest. I've reached back out to the provider for an effective date. MS"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","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","West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2023-08-01","1073983193","","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"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","West Texas Allergy, PA","Amerigroup","Participating","Payor Follow Up","2023-08-01","19103471","","2024-01-16","1/16/2024 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of August roster.  Have not received responses from previous requests.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","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","West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2023-05-29","2V0556","00608K","2023-06-22","Received confirmation of COI. MS"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2023-05-29","2V0556","00608K","2023-06-22","Received confirmation of COI. MS"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","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"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","West Texas Allergy, PA","Humana","Participating","Enrollment Complete","2023-08-10","1073983193","","2024-01-24","1/24/2024 Rcvd email from Priscilla Albertine at MQA with an updated from Humana.  Provider is PAR and linked to group TIN and both locations effective 8/10/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","TriWest HC Alliance","Pending Other Enrollment","Pending Contracting","","","","2025-01-14","Group contract request was submitted to rep hparke@triwest.com. Once they are ready to approve a contract, they will send it out and request a provider roster. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","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","Midland Medicine PA","Travelers WC","Participating","Enrollment Complete","2023-06-11","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Liberty Mutual","Participating","Enrollment Complete","2023-06-11","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Humana","Participating","Enrollment Complete","2024-01-26","","","2024-05-22","5/22/2024 Provider participating as of 1/26/2024 listed as PCP spoke to Jen R. call Ref#2000387504047. FC"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","Midland Medicine PA","Rail Road Medicare","Participating","Enrollment Complete","2023-06-01","Q00537215","","2023-08-21","Confirmed enrollment. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","Midland Medicine PA","TriWest HC Alliance","Participating","Payor Follow Up","2023-08-01","4929401","","2025-06-04","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Medicaid","Participating","Enrollment Complete","2023-06-01","","","2024-01-05","Welcome letter rcvd. Provider effective 06/01/2023. Jen Videan"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-25","","","2023-09-20","9/20/2023 Rcvd email from Scott & White that provider is PAR and linked to group TIN/location effective 9/25/2023.  DCannon"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","","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","","Amerigroup","Participating","Add Info Submitted","2023-09-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Suresh K Kota, MD","1609921782","47-5554737","TX","","Multiplan","Participating","Add Info Submitted","2023-09-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Tokkie Orogbemi, CPNP","1790435014","75-2133441","TX","Midland Pediatric Associates, PLLC","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"]
["Tokkie Orogbemi, CPNP","1790435014","75-2133441","TX","Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2023-09-28","7682322","","2023-10-19","10.16.2023 S/W LynP of Cigna @ 1-800-882-4462. Per rep, Provider is in network with Cigna and linked to the group and TIN# effective on 09/28/2023. No next recredentialing date available. PIN: 7682322. Servicing location is on file. No payer# available. Call ref# LynP10162023. - Willie Ravas"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2023-09-19","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","Premier Family Care, Inc","Molina","Participating","Enrollment Complete","2023-09-19","","","2024-08-06","Received email confirmation from Jessica Bess, provider is par and linked to TIN/location, eff. 09/19/2023. PA."]
["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","","Wellmed","Participating","Enrollment Complete","2023-09-19","","","2023-12-22","12/22/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","In Process","Add Info Submitted","","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2023-09-19","","","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 9/19/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","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","","HealthSmart PPO","Participating","Add Info Submitted","2023-09-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","Permian Cardiology Inc.","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"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","","Multiplan","Participating","Add Info Submitted","2023-09-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","Permian Cardiology Inc.","Triwest VA","Participating","Enrollment Complete","2024-02-15","","","2024-02-21","Received confirmation provider is par w/ Triwest VA per email from Scarlett Abigail, eff. 02/15/2024. PA."]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","Midland Community Healthcare Services","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."]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","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","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","Midland Community Healthcare Services","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","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","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","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","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","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","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","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"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","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","Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted","2023-09-08","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","","HealthSmart PPO","Participating","Add Info Submitted","2023-09-08","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-09-29","","","2024-02-28","Re-Cred has been completed. eff 9/23/23. MS"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-09-08","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","","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","Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2023-09-08","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Abbie Estes, PA","1952088411","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","Participating","Payor Follow Up","2025-04-08","1952088411","","2025-08-20","08/20/2025 AC: Verification request has been emailed to updates@primehealthservices.com, credentialing@primehealthservices.com, providerrelations@primehealthservices.com to verify provider credentialing status."]
["Abbie Estes, PA","1952088411","46-0950925","TX","Urgent Orthopedic Specialists, 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"]
["Abbie Estes, PA","1952088411","46-0950925","TX","Urgent Orthopedic Specialists, 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"]
["Abbie Estes, PA","1952088411","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Gallagher","Participating","Enrollment Complete","2023-08-07","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Abbie Estes, PA","1952088411","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 AC: Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-12-03","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 12/03/2024. PA."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-12-02","5018822","","2024-12-20","Received confirmation email. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","","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","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","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","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","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-07-30","","","2025-09-19","Received confirmation via phone call, provider participating eff date 7/30/2025, spoke to Yan call ref#1733661. FC"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-08","6474406","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/8/2023. FC"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-09-22","1376006403","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-08","6474406","","2024-05-20","5/20/2024- Spoke to Audrey call ref#6192840042, 616 N Main St location participating as of 2/1/2024. FC"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-09-01","","","2024-04-25","4/25/2024 provider enrolled as of 9/1/2023 via roster. FC"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2025-09-16","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/20/2023 for all locations. PIN is the NPI."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd eff. 5/21/2024\n616 N Main St. & 4705 Briarwood Ave  eff. 9/8/2023. AS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd eff. 5/21/2024\n616 N Main St. & 4705 Briarwood Ave  eff. 9/8/2023. AS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","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","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-09-08","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 09/08/2023. PA."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 09/01/2023, and linked to 616 Main St. location. PA."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","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","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-03-01","","","2024-07-19","Received roster from HP Delegation; provider is shown linked to TIN/locations, eff: 03/01/2024. PA."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1376006403","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 11/1/2023 for all locations. PIN is the NPI."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","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","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-08-11",""]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-08-11",""]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-09-09","09/09/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-09-09","09/09/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","Midland Inpatient Medical Association","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"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Add Info Submitted","2023-11-06","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","Midland Inpatient Medical Association","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"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","Midland Inpatient Medical Association","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"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","West Texas Allergy, PA","Ambetter","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","West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2023-09-08","1083394977","","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 9/8/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","953232543","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","1083394977","","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"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","West Texas Allergy, PA","USA PPO","Participating","Enrollment Complete","2023-09-08","1083394977","","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"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2025-08-12","16016463","","2025-08-12","08/12/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2024-02-15","","","2024-09-18","19 st location: Received email from TriWEst Healthcare this provider is loaded and active eff 2/15/2024. MS"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-11-01","6C5361","","2023-11-03","Received approval Letter. MS"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2014-08-01","1083979322","","2023-12-06","12/6/2023 Per TMHP web portal application has been approved.  Provider is PAR and linked to group/location effective 8/1/2014.  Revalidation date 10/16/2028.  TPI # 1083979322.  DCannon"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2024-01-01","","","2024-01-17","1/17/2024 Per follow-up email from Scott and White provider is PAR effective 1/1/2024.  DCannon"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2023-11-08","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Billy S Gao, MD","1699092304","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Billy S Gao, MD","1699092304","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-11-06","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","","","","2024-03-07","3/7/2024 Received Wellpoint roster, provider showing effective 12/4/2023. FC"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2023-12-04","00007115968","","2024-01-22","1/22/2024 Per UHC portal provider is PAR and linked to group TIN/location effective 12/4/2023. MPIN# 00007115968.  DCannon"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Add Info Submitted","2023-12-04","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-12-04","","","2024-09-09","Received confirmation from Aleece Moerbe via email provider participating as of 12/4/2023. FC"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","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","Midland Community Healthcare Services","TriWest HC Alliance","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","Midland Community Healthcare Services","TriWest HC Alliance","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","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","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","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-11-29","8412605","","2023-12-06","Received confirmation email of approval effective 11/29/23. MS"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","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","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","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","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2023-11-06","","","2024-05-20","5/20/2024 Provider participating as of 11/6/2023 via April roster. FC"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","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"]
["Briana Janene Smith, APRN-FNP-BC","1215488754","83-0358685","TX","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"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","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","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-07-26","","","2025-08-27","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/01/2023 for all locations. PIN is the NPI."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-15","1790315737","","2024-01-05","Welcome ltr rcvd. Provider effective 12/15/2023. Jen Videan"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-18","Group is not Tricare Credentialed and the payor is not accepting new enrollments at this time. MS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","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","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St. 08/05/2025 KC: Called 800-882-4462 and spoke w/ Jaq A at Cigna. Stated provider is totally OON and not link to the tax id.To be innetwork/credentialed rep advised provider must reach out cigna to initiate the application over the phone/call.TAT 60 cal days.Call ref# Jaq A 08/05/2025."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","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","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"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-12-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-06","Provider is linked. MS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-12-15","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 12/15/2023. PA."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-19","","","2025-08-19","08/19/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-25","","","2024-07-02","Received email from Angela Bates confirming location has been added to provider’s record, eff. 06/25/2024. PA."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","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","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."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-11-06","","","2024-10-31","Received confirmation via delegated roster provider participating as of 11/6/2023. FC"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2024-01-24","00390311","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  01/24/2024.  PA."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-19","","","2025-08-19","08/19/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2024-01-24","008766524","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  01/24/2024.  PA."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-11-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-11-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-11-06","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff.  11/06/2023. PA."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-11-06","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 11/06/2023. PA"]
["Neel N Shah, MD","1861752529","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-11-01","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 11/01/2023. PA."]
["Neel N Shah, MD","1861752529","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Re-Credentialing","2024-02-05","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Neel N Shah, MD","1861752529","75-2656723","TX","","First Health Coventry","Participating","Re-Credentialing","2024-03-01","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Neel N Shah, MD","1861752529","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-04-01","","","2024-11-13","2084V0102X is now showing a primary taxonomy code, effective 04/01/2024. Jen Videan"]
["Neel N Shah, MD","1861752529","75-2656723","TX","","Omni PPO","Participating","Re-Credentialing","2024-02-05","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","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","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2025-01-30","Received confirmation via email from Caprcock, provider participating as of 11/6/2023. FC"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-11-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-10-01","2231549","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-25","","","2024-07-02","Received email from Angela Bates confirming location has been added to provider’s record, eff. 06/25/2024. PA."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1841508462","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","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","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","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"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","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","","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","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"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","No Value Specified","2025-09-29","","","2025-09-29","09/29/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","1841508462","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 3/20/2024 for all locations. NPI# is PIN."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","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","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-15","1841508462","","2024-01-05","Welcome letter rcvd. Provider effective 12/15/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-12-15","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 12/15/2023. PA."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 11/6/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 11/6/2023. AS"]
["Jeremy Davis Dominguez, PA","1841508462","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"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1841508462","","2025-09-02","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1841508462","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2023 for all locations. PIN is the NPI."]
["Jeremy Davis Dominguez, PA","1841508462","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"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-01","","","2024-05-20","5/20/2024- Spoke to Audrey call ref #6192822735 616 N Main participating as of 2/1/2024. FC"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-01-22","","","2025-01-22","Received confirmation via BCBSTX email Provider participating. AS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2024-11-14","Please see status updates under Alliance WC payor line. Jen Videan"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","","First Health Coventry","Participating","Enrollment Complete","2024-02-01","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 02/01/2024, and linked to 616 Main St. location. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","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","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","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1376149153","","2025-09-08","09/08/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is not on file. PIN is NPI."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","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","","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"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-12","For Locations: 4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is not credentialed, out of network. Rep advised to have an over the phone application or send it via email at psscentral@cigna.com. TAT 60 calendar days. Call ref# Jay 08/06/2025"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-12-04","","","","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","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"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Payor Follow Up","","","","2024-04-30","Sent email to Multiplan rep Marcie Havens (marcie.havens@multiplan.com) requesting enrollment status update. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-01-12","","","2024-05-09","Per Marina Martinez of USA MCO, provider is par, eff. 01/12/2024, and linked to TIN/locations. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","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","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-21","","","2024-05-28","Spoke to Irish call ref#6193526649 all four location participating as of 5/21/2024. FC"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-12-04","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-12-04","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-10-01","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-12","08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is not credentialed, out of network. Rep advised to have an over the phone application or send it via email at psscentral@cigna.com. TAT 60 calendar days. Call ref# Jay 08/06/2025"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","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","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-09-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd., 616 N Main st, 4705 Briarwood Ave eff. 12/4/2023\n3490 E Yukon Rd eff. 9/1/2024. AS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-18","Received confirmation of enrollment. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-12-03","","","2025-02-17","Received email confirmation provider is enrolled, linked to TIN/location, eff. 12/03/2024. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","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","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-01-19","1376149153","","2024-02-13","Welcome ltr rcvd. Provider effective 01/19/2024. Only lists two locations per provider on website. Jen Videan"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-11-01","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  11/01/2023.  PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-02-08","","","2025-03-24","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 02/08/2021. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-02-08","","","2025-03-24","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 02/08/2021. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-11-01","","","2024-07-29","Received product roster. Provider is par and linked to TIN/location, eff. 11/01/2023."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-05-28","1376149153","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 2/21/2024 for all locations. NPI# is PIN."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","15380393","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-11-01","6E0916","","2023-11-29","Received approval letter effective 11/1/2023. MS"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2024-03-11","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 3/11/2024.  PA."]
["Bailey Bergman, PA","1447851639","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Re-Credentialing","2024-03-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-03-11","","","2024-05-29","As per Kodi from IMS, provider participating as of 3/11/2024 received via email. FC"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","","","","2024-04-01","Provider is showing active per the registry and linked to this location. MS"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Brittany P Price, RD","1922875160","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Enrollment Complete","","1922875160","","2024-03-06","Confirmed enrollment via provider directory. MS"]
["Brittany P Price, RD","1922875160","75-2656723","TX","Premier Family Care, Inc","USA PPO","Provider Type Not Enrolled","Enrollment Stopped","","","","2024-01-31","1/31/2024 Per LaNetrice Myart @ USA PPO, registered dieticians are not credentialed/enrolled through USA PPO.  There fore enrollment will be stopped for this provider.  DCannon"]
["Brittany P Price, RD","1922875160","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-02-05","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 02/05/2024. PA."]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2024-03-15","","","2024-05-23","Received email confirmation (from hpregion3@bswhealth.org) provider is PAR, eff. 3/15/2024, and linked to TIN/location. PA."]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-03-05","1861144","","2024-03-06","Received welcome letter. MS"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/5/2024 received via email. FC"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/5/2024 received via email. FC"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2024-02-05","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff. 02/05/2024.  PA."]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2024-02-05","","","2024-08-19","Received UHC provider roster. Provider is shown PAR and linked to TIN and location, eff. 02/05/2024. PA."]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2024-03-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 03/01/2024. PA."]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-02-05","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024  provider is PAR, eff. 02/05/2024. Location on file: 5615 Deauville BLVD, Suite 220. PA"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2024-03-15","","","2024-09-04","Roster received from the payor. The provider is listed as PAR, effective 03/15/2024, and is linked to the TIN and location. PA."]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2024-02-05","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff . 2/5/2024. PA."]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","","HealthSmart PPO","Participating","Enrollment Complete","2024-02-05","","","2024-07-04","7/4/2024 provider participating as of 2/5/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-12-20","","","2024-11-20","License update has been completed. Jen Videan"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","","United Health Care","Participating","Action Needed","2024-08-05","","","2024-11-26","Address listed as \"2012  Ohio Ave\" on product roster.  Will submit correction via delegated roster submission, PA."]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2024-08-15","","","2024-10-16","Received email confirmation from LaNetrice Myart provider is par, linked to TIN/location, eff. 8/15/2024. PA."]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","","Aetna","Participating","Enrollment Complete","","","","2024-11-20","Provider is linked to this location per the directory. MS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-09-09","","","2025-02-03","Received  confirmation via email from Karen Avalos, provider participating as of 9/9/2024. FC"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-09-09","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 9/9/2024. AS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-07-01","","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par but not linked to the group. unable to provide ID#. To link need to file maintenance request to their portal at tmhp.com. TAT is 30 bus days. Call ref# 51979045000"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-07-01","","","2025-08-18","08/18/2025 MQ: Called 800-925-9126 and spoke w/ Delia at Medicaid . Stated provider par and linked to the group. prov ID# is 488671501. Call ref# 51979045000"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-09-09","","","2025-03-12","Received confirmation via email, provider participating as of 9/9/2024. FC"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, effective 10/1/2024, linked to TIN & location, effective 10/1/2024."]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2025-01-01","","","2025-02-19","Per BSW rep Danielle , 1-800-321-7947, ref# CAS-19819034-P02Q1W2, provider is participating, linked to TIN/locations, eff. 1/1/2025. Provider is participating in the following plans: BSW Plus HMO & PPO, BSW Premier HMO &  PPO, & Medicare Advantage. PA."]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2024-09-09","","","2025-02-21","Received email from Network Relations-Humana, confirming provider is par, linked to TIN/location, eff.  09/09/2024. PA."]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-12","08.05.2025 MA: Called First Health Coventry @800-226-5116 to obtain FU status for the provider and spoke with Deshaun B. Per rep, provider is in network and linked under the TIN effective 10/01/2024. PIN is 3965845. Physical location is on file. Call ref# 1669742."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Briarwood location eff 3/7/2024. MS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-04-10","Eastridge, Andrews, Main St, and Longview location are all effective 3/13/2024. MS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-03-07","","","2024-04-15","4/15/2024- received email confirmation provider is par, eff.  04/16/2024, and participating with the following networks: PMC - Medicare Advantage PPO\nBCA - BlueChoice PPO\nBAV - Blue Advantage HMO\nHMO - Blue Essentials\nHME - Health Select. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-03-07","","","2024-04-15","4/15/2024- received email confirmation provider is par, eff.  04/16/2024, and participating with the following networks: PMC - Medicare Advantage PPO\nBCA - BlueChoice PPO\nBAV - Blue Advantage HMO\nHMO - Blue Essentials\nHME - Health Select. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-04-12","1184490161","","2024-11-14","Per Michelle Killough at michelle.killough@pswca.org location has been added to group profile. 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"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Action Needed","2024-09-13","","","2024-12-17","Resubmit locations- 616 N Main St, 6301 Andrews, 6950 Eastridge, and 5514 Big Spring-  to payor. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","USA PPO","Participating","Action Needed","2024-09-13","","","2024-12-17","Resubmit locations- 616 N Main St, 6301 Andrews, 6950 Eastridge, and 5514 Big Spring-  to payor. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-04-05","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 04/05/2024. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-03-06","6M4476","","2024-03-25","Received approval. MS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-04-05","","","2024-07-31","Received email confirmation provider is par and linked to TIN/location, eff. 04/05/2024. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-12","","","2025-08-12","08/12/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 2/1/2025. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd., 616 N Main st, 4705 Briarwood Ave eff. 10/4/2024\n3490 E Yukon Rd eff. 8/31/2024. AS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-13","For Locations: 6950 Eastridge Rd./6301 Andrews Hwy/ 616 N Main St./4705 Briarwood Ave 08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is not credentialed, out of network. Rep advised to have an over the phone application or send it via email at psscentral@cigna.com. TAT 60 calendar days. Call ref# Jay 08/06/2025"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-03-11","","","2024-07-23","As per Kim Patterson from Caprock, provider participating as of 3/11/2024 via email. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-04-05","8474477","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 4/5/2024. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-04-05","8474477","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 4/5/2024. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","1184490161","","2025-09-15","09/15/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 07/17/2024 for all locations. NPI# is PIN."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2024-04-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2024-04-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-10-02","Per the Tricare portal, the provider is linked. MS"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-04-05","","","2024-05-29","Provider participating as of 4/5/2024 received via email from Kodi Kox. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-04-05","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 04/05/2024. PA"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-04-12","1184490161","","2024-04-22","Approval ltr rcvd. Provider effective 04/12/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-05-05","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 05/05/2024. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-04-12","","","2024-04-22","Please see status updates under Alliance WC payor line. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-03-01","","","2024-07-31","Received email confirmation provider is par and linked to location, eff. 3/01/2024. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-06-14","1184490161","","2024-06-14","Approval ltr rcvd. Effective 06/14/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-06-14","1184490161","","2024-06-14","Approval ltr rcvd. Effective 06/14/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","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 G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Application Submitted","2024-03-07","","","2024-04-15","4/15/2024 Delegated roster submitted.  FC"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2024-10-01","8218340","","2025-01-29","Received confirmation from Mary Hanna via email, provider participating as of 10/1/2024. FC"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","HealthSmart PPO","Participating","Enrollment Complete","2024-09-09","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 9/9/2024. AS"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","Medicaid","Participating","Enrollment Complete","2024-08-01","","","2024-10-16","Approval ltr rcvd. Effective 08/11/2024. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2024-06-28","","","2024-07-24","Please see status updates under Alliance WC payor line. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","Midland Texas Orthopedic Group Inc","Humana","Participating","Confirm Par Status","2024-09-09","","","2025-02-11","Received email confirmation provider is par, linked to TIN & location, eff. 09/09/2024. PA"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","Alliance WC","Participating","Enrollment Complete","2024-06-28","1295354264","","2024-07-24","Approval Ltr rcvd. Effective 06/28/2024. Jen Videan"]
["Laura V Salcido, PA","1669755906","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-07-01","","","2024-07-17","Received July validation report: the provider is linked to the location/TIN, eff. 7/01/2024. PA."]
["Laura V Salcido, PA","1669755906","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-05-20","","","2024-09-04","Confirmed via portal, provider is linked and active. MS"]
["Laura V Salcido, PA","1669755906","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2024-06-10","","","2025-05-12","Received product roster from UHC; provider is linked to TIN/location, eff. 06/10/2024. PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2025-02-06","Received confirmation via telephone call spoke to Daniel call ref#1407169, provider participating as of 8/1/2024. First Health added suite A to 4705 Briarwood location, I will resubmit correction on February roster. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024.  Requested roster listing locations linked to provider via email. PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2026-11-24","","","2025-02-20","Confirmed enrollment via Tricare Portal. MS"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-04-30","","","2024-04-30","Received email confirmation provider is PAR, eff. 04/30/2024, participating in the following networks: BAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","Tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-07-01","","","2024-07-31","Received email confirmation provider is PAR and linked to TIN & location, eff. 07/01/2024. PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-05-06","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 05/06/2024.  PA"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","Tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-29","1548026099","","2024-11-14","Per Michelle Killough at michelle.killough@pswca.org location has been added to group profile. 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"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2024-05-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-05-06","","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-05-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  05/01/2024.  PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-10","1548026099","","2024-05-17","Please see status updates under Alliance WC payor line. Jen Videan"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-05-14","","","2024-05-14","Provider enrolled at the briarwood location eff 4/30/2024. MS"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-05-06","","","2024-07-31","Received email confirmation provider is PAR and linked to TIN & location, eff. 05/06/2024. PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-05-06","","","2024-07-31","Received email confirmation provider is PAR and linked to TIN & location, eff. 05/06/2024. PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","Received email confirmation provider is PAR and linked to TIN & location, eff. 06/06/2024. PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","Received email confirmation provider is PAR and linked to TIN & location, eff. 06/06/2024. PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-05-06","","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-05-06","","","","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","Tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-07-01","","","2024-06-28","Group enrollment has been approved and this location has been linked and is active effective 7/1/2024. MS"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-05-06","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 5/6/2024. AS"]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-05-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1093796435","","2024-05-06","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"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-18","Received email confirmation from PPHP, provider is linked to the location/TIN, eff. 7/11/2024. PA."]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-04-12","Locations are not Tricare Credentialed and they are not accepting new providers. MS"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-04-12","","","2024-04-28","Provider is linked to all 5 locations eff 4/12/24. MS"]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-05-06","","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Patrick call ref#20485220 via phone call, provider participating eff date 2/1/2025. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-10","1093796435","","2024-05-17","Please see status updates under Alliance WC payor line. Jen Videan"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-04-26","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 04/26/2024. PA"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-12","For Locations: 6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./08.06.2025 KF: Called Cigna @ 1-800-882-4462 and spoke with Paul. Per rep, provider is OON. To be credentialed and par, rep advised to send an email to psscentral@cigna.com. TAT is 60 cal days. Call ref# Paul C08062025"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-06","8016068","","2024-06-19","6/19/2024 Spoke to Ethan S. call ref#6195709020 provider participating as of 5/6/2024. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-06","8016068","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 5/6/2024. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2025-08-12","08.06.2025 KF: Called Cigna @ 1-800-882-4462 and spoke with Paul. Per rep, provider is OON. To be credentialed and par, rep advised to send an email to psscentral@cigna.com. TAT is 60 cal days. Call ref# Paul C08062025"]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-05-06","","","2024-05-27","Received email confirmation from Christy Henson (CHenson@pphealthplan.com) provider is PAR and linked to TIN/locations, eff, 5/06/2024. PA"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-05-06","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 5/6/2024. AS"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-12-03","","","2025-02-06","Received confirmation via phone call from Daniel call ref#1407169, provider participating as of 12/3/2024. FC"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For Locations: 6950 Eastridge Rd./ 6301 Andrews Hwy/ 616 N Main St./ Verification request has been emailed to TXMAContracting@CignaHealthcare.com to verify provider credentialing status."]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. Requested roster listing locations linked to provider via email. PA."]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. Requested roster listing locations linked to provider via email. PA."]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main St., 6301 Andrews Hwy, 6950 Eastridge Rd., 4705 Briarwood Ave eff. 10/4/2024. AS"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-03-13","6P2387","","2024-04-24","Received enrollment confirmation eff 3/13/24. MS"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-03-13","Q00738696","DX4335","2024-05-14","Received approval. MS"]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Enrollment Complete","2024-05-10","1093796435","","2024-05-17","Welcome ltr rcvd. Effective 05/10/2024. Jen Videan"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-07-26","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 6/1/2024 for all locations. PIN is the NPI."]
["Rizwan Asim, MD","1205287646","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2024-10-07","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 10/7/2024. FC"]
["Rizwan Asim, MD","1205287646","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Kwame B Agyeman, MD","1285863753","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, effective 10/1/2024, linked to TIN & location, effective 10/1/2024."]
["Kwame B Agyeman, MD","1285863753","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2024-10-01","9619640","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/1/2024. FC"]
["Kwame B Agyeman, MD","1285863753","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2024-09-01","","","2025-02-04","Received confirmation from Marva call ref#1403456 via phone call, provider participating as of 9/1/2024. FC"]
["Hamza Muhammad Tola, MD","1154818342","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2024-09-06","Q00922999","DW7662","2025-01-06","Provider is active. MS"]
["Hamza Muhammad Tola, MD","1154818342","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2024-10-07","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 10/7/2024. FC"]
["Hamza Muhammad Tola, MD","1154818342","47-5554737","TX","Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-31","Panel is closed. MS"]
["John W Romeo, MD","1447661764","47-5554737","TX","","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["John W Romeo, MD","1447661764","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2025-01-07","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff. 1/07/2025. PA."]
["John W Romeo, MD","1447661764","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2025-01-07","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff. 1/07/2025. PA."]
["John W Romeo, MD","1447661764","47-5554737","TX","","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["John W Romeo, MD","1447661764","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2024-10-07","","","2025-02-21","Received email from Network Relations-Humana, confirming provider is par, linked to TIN/location, eff.  10/07/2024. PA."]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","Midland Inpatient Medical Association","PPHP","Participating","Enrollment Complete","2024-10-07","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 10/07/2024. PA."]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2024-10-01","Q00922944","DW7662","2025-01-06","Provider is enrolled. MS"]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff.  11/01/2024. PA."]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","Participating","Enrollment Complete","2024-10-07","6748656","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Pierre Monverdy Agnant, MD","1669868568","47-5554737","TX","","Amerigroup","Participating","Enrollment Complete","2024-10-07","","","2025-01-29","Received confirmation via roster, provider participating as of 10/7/2024. FC"]
["Ugochukwu Ikechi Maduforo, MD","1447630033","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Ugochukwu Ikechi Maduforo, MD","1447630033","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff.  11/01/2024. PA."]
["Nadeem Jaffer, MD","1427302025","47-5554737","TX","","Wellmed","Participating","Enrollment Complete","2025-01-09","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff. 1/09/2025. PA."]
["Nadeem Jaffer, MD","1427302025","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2024-10-07","","","2025-03-12","Received confirmation via email, provider participating as of 10/7/2024. FC"]
["Nadeem Jaffer, MD","1427302025","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2024-10-07","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 10/07/2024. PA."]
["Nadeem Jaffer, MD","1427302025","47-5554737","TX","","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Nadeem Jaffer, MD","1427302025","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2024-10-07","","","2025-02-03","Received  confirmation via email from Karen Avalos, provider participating as of 10/7/2024. FC"]
["Sahil Batta, MD","1801324306","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sahil Batta, MD","1801324306","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-12-27","Received email form UHC, confirming provider is par, linked to TIN & location, eff. 10/07/2024. PA."]
["Sahil Batta, MD","1801324306","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2024-10-28","","","2025-02-06","Per LaTrisha @ TMHP, ticket# 50492669000, enrollment is closed-approved. Effective 10/28/2024. There is no welcome available. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","1366816829","","2024-07-24","Provider linked to all locations. MS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","1366816829","","2024-07-02","Provider is linked to Briarwood location eff 6/13/24. MS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Add Info Submitted","2024-08-28","","","2024-09-19","Submitted  Disclosure Q&A to BCBSTX. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-08-28","","","2024-09-19","Received email confirmation provider has been added to Network, under TIN/locations, eff. 8/28/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Add Info Submitted","2024-08-28","","","2024-09-17","Submitted  \"Standard Authorization, Attestation and Release\" form to BCBSTX. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2017-05-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 5/1/2017. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2017-05-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 5/1/2017. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-05-21","","","2025-08-27","08/27/25 MQ:  Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/01/2024 for all locations. PIN is the NPI."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-21","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is the NPI. Loc is not on file."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-05-10","6S2250","","2024-06-12","Received provider's welcome letter. MS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-07-24","","","2025-02-18","Received verbal confirmation from Karen Avalos provider is linked to 4705 Briarwood Ave, eff. 07/01/2024;  Also received email confirmation provider reinstated, linked to remaining locations, eff. 07/24/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","Tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2025-02-06","Received confirmation via phone call from Daniel call ref#1407169, provider participating as of 8/1/2024. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-21","1366816829","","2024-10-01","Approval ltrd rcvd. Effective 08/16/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-21","1366816829","","2024-10-01","Approval ltrd rcvd. Effective 08/16/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. \nLocation is linked to provider per payor website. PA."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-07-01","","","2024-10-31","Received confirmation via delegated roster provider participating as of 7/1/2024. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-07-01","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 7/1/2024.  PA"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","Tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-21","","","2024-10-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 7/1/2024\n616 N Main st eff. 8/1/2023\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd & 4705 Briarwood Ave eff. 8/1/2023. AS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","","","2025-06-23","Received confirmation via email from Mary Hanna, provider participating as of 10/7/2024. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-06","","","2025-08-06","08/06/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-06-04","1366816829","","2024-06-11","Welcome ltr rcvd. Provider effective 06/04/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2025-08-06","For Locations:616 N Main St./6301 Andrews Hwy/6950 Eastridge Rd./08.04.2025 JB: Verification request has been emailed to SPNEAST@sedgwickcms.com, providerdata@careworks.com, Cynthia.Clancy@sedgwick.com to verify provider credentialing status."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For Locations: 6301 Andrews Hwy/6950 Eastridge Rd. / 616 N Main St./Verification request has been emailed to TXMAContracting@CignaHealthcare.com to verify provider credentialing status."]
["Dharti Rajesh Patel, MD","1609364777","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2024-11-04","","","2025-05-09","Received product roster from UHC. Provider is listed PAR, linked to TIN/location, eff. 11/04/2024. PA."]
["Dharti Rajesh Patel, MD","1609364777","47-5554737","TX","Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Dharti Rajesh Patel, MD","1609364777","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2024-11-04","","","2025-02-04","Received confirmation from Jessica Bess via email, provider participating as of 11/4/2024. FC"]
["Khiem Duc Nguyen, MD","1316922511","","TX","","Triwest VA","In Process","Payor Follow Up","","","","2025-09-10","Received email from txintaketeampiermailbox@bcbstx.com stating application was received and under review case#17993110.  MR"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2025-06-25","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Vinitha, ref # 05414545)  that provider is participating with network, effective 06/25/2025. ML"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2024-07-01","","","2024-08-16","Received confirmation from Jessica Bess via email provider participating as of 7/1/2024. FC"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2025-06-25","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Vinitha, ref # 05414545)  that provider is participating with network, effective 06/25/2025. ML"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Enrollment Stopped","Enrollment Complete","","","","2025-03-04","4214 Andrews location eff 6/17/2024. MS"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2024-07-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  7/1/2024.  PA."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-17","None of the 3 locations are Tricare credentialed, and since the panel is closed to new enrollments there is nothing else needed at this time. MS"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2024-08-01","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff. 08/01/2024. PA."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2024-08-01","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff. 08/01/2024. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","Superior","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-05-28","","","2024-09-03","Received confirmation. MS"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-08-23","Provider is active and linked to Briarwood location eff 7/30/2024. MS"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","Triwest VA","Participating","Enrollment Complete","2024-11-15","","","2024-11-13","Received email confirmation from Scarlett A, provider is par and linked to TIN/locations, eff. 11/15/2024. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, PA","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-17","For Locations:5424 19th St/5000 Briarwood Ave/07/17/2025 MQ: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","Medicaid","Participating","Enrollment Complete","2024-05-28","1598517369","","2025-01-29","Approval ltr rcvd. Effective 05/28/2024. Jen Videan"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2024-10-08","Received confirmation via email from FirstHealth provider participating eff date 8/1/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, PA","HealthSmart PPO","Participating","Enrollment Complete","2024-08-05","","","2024-10-29","Received notification via email, provider participating as of 8/5/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-08-05","","","2024-09-18","Received email confirmation from Karen Avalos stating August 2024 roster has been processed. Provider is par and linked to TIN/Location, eff. 8/5/2024. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","USA PPO","Participating","Enrollment Complete","2024-08-15","","","2024-11-08","Received email confirmation from LaNetrice M,  provider is par and linked to TIN & locations, eff. 8/15/2024. PA ."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2024-08-05","","","2024-09-20","Received notification via email from Jessica Bess, provider participating as of 8/5/2024. FC"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2024-08-05","","","2024-09-20","Received notification via email from Jessica Bess, provider participating as of 8/5/2024. FC"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2024-08-13","","","2024-09-30","Received confirmation via email from payor, provider participating as of 8/13/2024, FC"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2024-07-01","","","2024-07-22","Received welcome letter. MS"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-11-15","","","2024-11-13","Received email confirmation from Scarlett A, provider is par and linked to TIN/locations, eff. 11/15/2024. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Aetna","Participating","Enrollment Complete","2024-08-01","","","","Received confirmation via email from Aetna, provider participating eff date 8/1/2024. FC"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","United Health Care","Participating","Follow Up Complete","2024-08-05","8960512","","2024-12-30","Spoke with UHC rep Sergio via online chat (reference #04942809), case #PR-8740637 is closed. Individual Exchange line of business is not accepting applications at this time, including those for delegation. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2024-07-01","4357405","","2024-07-30","Received confirmation of enrollment. MS"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","CAQH","Provider Load","In House Enrollment","2024-07-02","","","2024-07-02",""]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2024-09-05","1144933367","","2024-09-04","Roster and email confirmation received from the payor. Payor confirmed provider is PAR, eff. 9/5/2024, linked to the TIN and locations. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Galaxy Health","Participating","Enrollment Complete","2024-08-05","","","2024-09-18","Received email confirmation from Karen Avalos stating August 2024 roster has been processed. Provider is par and linked to TIN/Location, eff. 8/5/2024. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["George J Germanos, MD","1144858390","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2024-10-31","","","2024-11-27","Provider is linked to this location. MS"]
["George J Germanos, MD","1144858390","47-5554737","TX","Midland Inpatient Medical Association","PPHP","Participating","Enrollment Complete","2024-10-07","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 10/07/2024. PA."]
["George J Germanos, MD","1144858390","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Aliaksandr Savitski, MD","1053654863","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2024-10-07","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 10/7/2024. FC"]
["Aliaksandr Savitski, MD","1053654863","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Samantha Anne Hall, DPM","1942592803","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2024-12-02","","","2025-05-12","Received product roster from UHC; provider is linked to TIN/location, eff. 12/02/2024. PA."]
["Samantha Anne Hall, DPM","1942592803","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2024-12-02","","","2025-03-13","Provider participating as of 12/2/2024, recived via delegated roster from Wellpoint. FC"]
["Samantha Anne Hall, DPM","1942592803","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Samantha Anne Hall, DPM","1942592803","75-2656723","TX","Premier Family Care, Inc","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-27","Received confirmation via email from Coventry cssupport@cvty.us.com, provider participating as of 2/1/2025. FC"]
["Aimel Azizi, MD","1144480997","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2024-11-18","","","2025-02-17","Confirmed with Emily L. (1-800-626-2741), ref# 2000437199418,  provider is in-network, linked to TIN & location, effective 11/18/2024. PA."]
["Aimel Azizi, MD","1144480997","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-11-04","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 11/04/2024. PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-12-26","","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-12-03","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff. 12/03/2024. PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-11-01","Q00897593","DX4335","2024-11-27",""]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-02-03","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 02/03/2025. PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2025-08-19","For Locations: 6301 Andrews Hwy/4705 Briarwood Ave/6950 Eastridge Rd. /616 N Main St./3490 E Yukon Rd./08/15/2025 MQ: Checked Texas Mutual's directory to check provider status but provider is not found."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status update under Alliance WC payor line. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-11-04","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-08","Panel is closed to any new group/locations. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-08","Panel is closed to any new group/locations. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-11-01","7B3481","","2024-11-14","Provider enrolled per PECOS. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-11-04","","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-11-25","","","2024-11-22","Received welcome letter. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-11-01","","","2025-06-10",""]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Triwest VA","Enrollment Stopped","Enrollment Denied","","","","2025-02-13","Received email from Scarlett Abigail, \"Provider is set up as urgent care and is ineligible for the TriWest network.\nThanks,\nScarlett\". PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-12-03","","","2025-01-03","Provider is active and linked to the group record. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-10-16","","","2025-02-20","Confirmed enrollment via Tricare Portal. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-10-16","","","2025-02-20","Confirmed enrollment via Tricare Portal. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-10-16","","","2024-11-26","Enrollment complete for all 5 original location. MS"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-11-04","","","2025-01-30","Received confirmation via email from Caprock, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-11-04","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 11/04/2024. PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-11-04","","","2025-02-21","Per email from PPHP representative Keandra Walker, provider is participating and linked to TIN and location, effective 11/04/2024. PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-04","Recceived confirmation via email from LaNetrice Myart, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","0452423","","2025-08-11","For Locations: 4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 MG: Called Cigna @ 1-800-882-4462 to obtain PNP/FU status for the provider and spoke to Penny. Per rep, provider is out of network. To be par, initiate an over the phone application. If there's more than 6 providers to be par, we can email them but we need to call them first for the ticket#. TAT 60 CD. Call ref# Penny B. 08/05/2025."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-02-03","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 02/03/2025. PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-02-03","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 02/03/2025. PA."]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-02-19","","","2025-09-16","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 02/19/2025 for all locations. PIN is the NPI"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 11/4/2024. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-17","","","2024-10-16","Received welcome letter from BCBSTX via email. Provider is participating, eff. 10/17/2024, in the following networks: Blue Advantage HMO, BlueChoice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO. PA."]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-11-04","","","2025-01-30","Received confirmation via email from Caprcock, provider participating as of 11/4/2024. FC"]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 11/4/2024. FC"]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-04","Recceived confirmation via email from LaNetrice Myart, provider participating as of 11/4/2024. FC"]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","In Process","No Value Specified","","","","2025-08-20","08/20/2025 MQ: Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing  status."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","CAQH","In Process","In House Enrollment","2024-11-01","","","2025-01-21","1/21/2025- Per Priscilla email - Provider Maintains CAQH"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2024-11-04","","","2025-05-09","Received product roster from UHC. Provider is listed PAR, linked to TIN/location, eff. 11/04/2024. PA."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2024-11-21","9443693","","2024-12-05","Received confirmation email. MS"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 11/4/2024. FC"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2024-11-04","","","2025-01-30","Received confirmation via email from Caprock, provider participating as of 11/4/2024. FC"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2024-11-04","","","2025-02-21","Received email confirming provider is par, linked to TIN/location, eff. 11/04/2024. PA."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2024-11-04","","","2025-05-09","Received product roster from UHC. Provider is listed PAR, linked to TIN/location, eff. 11/04/2024. PA."]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Kirubel E Adafre, MD","1700381852","47-5554737","TX","","HealthSmart PPO","Participating","Enrollment Complete","2025-05-05","","","2025-07-10","Received confirmation via email from Emily Starr, provider participating eff 5/5/2025. FC"]
["Kirubel E Adafre, MD","1700381852","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2025-05-05","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Vinitha, ref # 05414545)  that provider is participating with network, effective 05/05/2025. ML"]
["Kirubel E Adafre, MD","1700381852","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2025-05-05","","","2025-07-08","Received email from Marcus Wester confirming provider is par, linked to TIN/location, eff. 5/5/25. PA."]
["Kirubel E Adafre, MD","1700381852","47-5554737","TX","","IMS","Participating","Enrollment Complete","2025-05-05","","","2025-05-22","Received confirmation via email from Addella Yarnold from IMS, provider participating as of 5/5/2025. FC"]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","","Aetna","Participating","Enrollment Complete","2025-04-08","","","2025-08-12","08/05/2025 TE: Called 1-800-353-1232 and spoke with John at Aetna. Provider is linked to the TIN as in network. Location is on file. PIN 7007955. Call ref# 256056117"]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","Premier Family Care, Inc","Multiplan","No Value Specified","Application Submitted","","","","2025-02-14","Submitted application via delegated roster submission on 2/14/2025. FC"]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2025-02-03","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 02/03/2025. PA."]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","","Cigna","Participating","Enrollment Complete","2025-03-01","9497805","","2025-03-11","Received confirmation email of approval. MS"]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","In Process","Action Needed","","","","2025-07-15","Initiate Enrollment. Aetna approved. MS"]
["Payton Eliot Harris, DO","1922757764","  47-5554737","TX","","Rail Road Medicare","Participating","Enrollment Complete","2025-08-01","","","2025-07-09","Received Confirmation VIA Palmetto GBA website provider participating effective 08/01/2025 RR PTAN#Q01065518. MR"]
["Payton Eliot Harris, DO","1922757764","  47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Application Resubmitted","2025-08-01","","","2025-07-01","Application was resubmitted for updates. Application was approved on 6/29/2025 - Tracking number: T062020250003175"]
["Payton Eliot Harris, DO","1922757764","  47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2025-08-01","","","2025-08-28","Received confirmation via email from Mary Hana, provider participating eff date 8/1/2025. FC"]
["Payton Eliot Harris, DO","1922757764","  47-5554737","TX","","CAQH","Participating","CAQH Reattested","2025-08-15","","","2025-08-15","08/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Payton Eliot Harris, DO","1922757764","  47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2025-07-08","","","2025-09-17","Received notification via UHC online chat box, (spoke with Jennifer, ref #05438132) confirming provider's in-network status with Commercial, Medicare and Medicaid contracts, effective 07/08/25. ML"]
["Evisencia G Mathurin, APRN-NP","1407472129","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2024-04-14","","","2025-07-25","Approval ltr rcvd. Effective 04/14/2025. Jen Videan"]
["Evisencia G Mathurin, APRN-NP","1407472129","47-5554737","TX","Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2025-05-01","","","2025-05-07","Received validation report from SHP; provider is listed as PAR, linked to TIN/location, eff. 5/1/2025. PA"]
["Evisencia G Mathurin, APRN-NP","1407472129","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2025-04-07","","","2025-05-22","Received confirmation via email from Emily Starr from HealthSmart on 05/21/25.Effective date of 4/7/2025.  VA"]
["Raymond A Barlow, II, APRN-NP","1710315106","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2025-04-07","","","2025-05-01","Per TMHP, enrollment complete. Effective 04/07/2025. Jen Videan"]
["Lenita L Hinkle, APRN-NP","1477948636","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2025-04-07","","","2025-05-22","Received confirmation via email from Addella Yarnold from IMS on 05/19/25.Effective date of 4/7/2025.  VA"]
["Lenita L Hinkle, APRN-NP","1477948636","","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2025-04-07","","","2025-07-16","Received confirmation via email from firsthealthcustomerservicemailbox@aetna.com. Provider participating effective 4/7/25 ML."]
["Lenita L Hinkle, APRN-NP","1477948636","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2025-04-07","","","2025-06-27","Received email from Karen Avalos confirming provider is linked to TIN/location, eff. 4/7/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-03-03","","","2025-05-27","Received email from Keandra W. confirming  March roster has been processed. Provider now linked to TIN/locations, eff 3/3/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-03-03","","","2025-05-01","Received confirmation via email from Addella Yarnold, provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-04-15","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 04/15/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-04-15","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 04/15/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-04-11","1407668734","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-07-02","Provider does not need to be enrolled as all claims are billed through the group under the ancillary contract. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-02-04","7K1850","","2025-03-25","Provider has been linked to to both of group's PTANS. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-02-04","7K1850","","2025-03-25","Provider has been linked to to both of group's PTANS. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","In Process","Payor Follow Up","","","","2025-07-09","Requested enrollment status via email, sent to   payor. ML"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-03-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 3/1/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-03-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 3/1/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-03-03","","","2025-05-01","Received confirmation via email from Addella Yarnold, provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-03-03","","","2025-05-01","Received confirmation via email from Addella Yarnold, provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2025-05-01","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 5/1/2025 for all locations. PIN is the NPI."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-03-01","","","2025-09-19","Received confirmation via phone call, provider participating eff date 3/1/2025, spoke to Nicole B. Call ref#1733707. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-04-15","","","2025-05-09","Received email confirming provider is participating (PAR), linked to the correct TIN and location, effective 04/15/2025. Provider is enrolled in the following networks:\nHME – Health Select\nBAV – Blue Advantage HMO\nBCA – BlueChoice PPO\nHMO – Blue Essentials\nPMC – Medicare Advantage PPO. PA"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-04-11","1407668734","","2025-05-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-04-11","1407668734","","2025-05-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-03-03","","","2025-05-16","Received notification from Mary Rodgriguez via email, provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-03-03","8217000","","2025-04-15","Receved confirmation via email from Mary Hanna, provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-04-01","","","2025-04-14","Provider listed PAR per SHP April validation report, eff. 04/01/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-03-03","","","2025-04-22","Received via email from Emily Starr provider participating as of 3/3/2025. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-03-14","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 03/14/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-03-14","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 03/14/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-03-03","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 03/03/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all locations. PIN is the NPI."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all locations. PIN is the NPI."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-09-09","09/09/2025 per email CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-09-09","09/09/2025 per email CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-03-03","","","2025-05-12","Received email confirmation from Karen Avalos provider is participating, linked to TIN/location, eff.  03/03/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-03-03","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 03/03/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-02-04","Q01054617","","2025-06-18","Provider is enrolled. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-02-04","Q01054617","","2025-06-18","Provider is enrolled. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-04-01","","","2025-04-14","Provider listed PAR per SHP April validation report, eff. 04/01/2025. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-04-01","","","2025-04-14","Provider listed PAR per SHP April validation report, eff. 04/01/2025. PA."]
["Jeanette K Cala, MD","1629718622","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation of provider enrollment effective 7/8/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Jeanette K Cala, MD","1629718622","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Vidya Bharati Sinha, MD","1922731322","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2025-07-08","","","2025-09-17","Received notification via UHC online chat box, (spoke with Jennifer, ref #05438132) confirming provider's in-network status with Commercial, Medicare and Medicaid contracts, effective 07/08/2025. ML"]
["Vidya Bharati Sinha, MD","1922731322","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Neel Bhan, MD","1174085005"," 75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","Pending Info/Document","2025-09-11","","","2025-09-11","09/11/2025 Unable to Reattest due to missing valid COI-dvineyard"]
["Neel Bhan, MD","1174085005"," 75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2025-08-04","","","2025-09-17","Per email from Mary, the provider is enrolled, and the effective date is 8/4/25. SG"]
["Neel Bhan, MD","1174085005"," 75-2656723","TX","","Aetna","Participating","Enrollment Complete","2025-09-15","8836467","","2025-08-21","Welcome email rcvd. Effective 09/15/2025. PIN: 8836467. Jen Videan"]
["Neel Bhan, MD","1174085005"," 75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Neel Bhan, MD","1174085005"," 75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2025-09-01","","","2025-09-08","Per the September SHP Validation report, provider is enrolled, linked to TIN/location, eff. 9/1/2025.  ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-06-02","","","2025-07-10","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 6/2/25.  ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-04-15","Q01054677","","2025-06-18","Provider enrolled. MS"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-08-20","08/20/2025 AC: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ 5514 N Big Spring St Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-08-20","08/20/2025 AC: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ 5514 N Big Spring St Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-06-02","","","2025-07-18","Received confirmation via email from Addella Yarnold, provider participating effective 6/2/2025. FC"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-06-02","","","2025-08-28","Received confirmation of provider enrollment effective 06/02/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-07","","","2025-08-07","08/07/2025 CAQH Reattested-updated Cred Cont-dvineyard"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-06-13","1285403113","","2025-06-25","Welcome ltr rcvd. Effective 06/13/2025. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-06-13","1285403113","","2025-06-25","Welcome ltr rcvd. Effective 06/13/2025. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-05-06","","","2025-05-12","Received email confirmation from BCBSTX that the provider is participating, effective 05/06/2025. The provider is enrolled in the following networks:\nBlue Choice PPO – 05/06/2025\nBlue Advantage HMO – 05/06/2025\nBlue Essentials HMO – 05/06/2025\nHealth Select – 05/06/2025\nMedicare Advantage PPO – 05/06/2025\nTriWest – 01/01/2025\nPAR – 04/19/2024. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1285403113","","2025-09-10","09/10/2025 MQ: Per email response received on 8/26/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/26/2025 for all locations. PIN is the NPI."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1285403113","","2025-09-10","09/10/2025 MQ: Per email response received on 8/26/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/26/2025 for all locations. PIN is the NPI."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-06-02","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 6/2/2025. ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-06-02","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 6/2/2025. ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2025-06-13","Submitted applicatio via roster. FC"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-06-02","","","2025-07-29","Received confirmation via email from Emily Starr, provider participating effective 6/2/2025. FC"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-06-02","","","2025-07-29","Received confirmation via email from Emily Starr, provider participating effective 6/2/2025. FC"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-07-15","","","2025-08-05","Received email from BSW confirming provider is par, linked to TIN/location, eff. 7/15/2025. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Resubmitted","","","","2025-08-25","08/25/2025 AC: For locations: 5514 N Big Spring St/ 3490 E Yukon Rd./ 616 N Main St./ 6301 Andrews Hwy/ 6950 Eastridge Rd./ 4705 Briarwood Ave Checked Texas Mutual's directory to check provider status, provider cannot be found."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-08-20","1285403113","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 8/20/2025 for all locations. NPI# is PIN."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-06-02","","","2025-07-17","Received confirmation via email from Provider_Services_Shared.T8@90degreebenefits.com. Provider participating effective 6/2/25 ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-04-15","7M5460","","2025-04-25","Provider is active. MS"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-04-15","7M5460","","2025-04-25","Provider is active. MS"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-06-02","","","2025-06-24","Received email from PPHP (pphpprovidernetwork@pphealthplan.com) confirming provider is participating, linked to TIN/location, eff. 6/2/2025. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-06-02","","","2025-07-18","Received confirmation via email from Addella Yarnold, provider participating effective 6/2/2025. FC"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-06-02","","","2025-08-18","Received email confirming provider's participation on network under the TIN/All Locations effective 6/2/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-09-01","","","2025-09-30","Per Emma, the provider's effective date is 9/1/2025 ref#21352637-SG"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-06-02","","","2025-08-06","Received confirmation via phone call provider participating eff date 6/2/2025, spoke to Rachel (call ref# 1672166). FC"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-06-02","","","2025-08-06","Received confirmation via phone call provider participating eff date 6/2/2025, spoke to Rachel (call ref# 1672166). FC"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-06-13","1285403113","","2025-06-25","Please see status updates under Alliance WC payor line. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-07-01","8980080","","2025-07-16","Received confirmation via email (roster) from Brandy Smith. Provider participating effective 7/1/25 ML"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1285403113","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1285403113","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-05-08","","","2025-05-12","Received email confirmation from BCBSTX that the provider is participating, effective 05/12/2025. The provider is enrolled in the following networks:\nBlue Choice PPO – 05/08/2025\nBlue Advantage HMO – 05/08/2025\nBlue Essentials HMO – 05/08/2025\nHealth Select – 05/08/2025\nMedicare Advantage PPO \nPAR – 02/21/2025\nPA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-06-02","","","2025-07-10","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 6/2/25.  ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-06-02","","","2025-07-10","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 6/2/25.  ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-06-02","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Locations effective 6/2/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-06-02","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Locations effective 6/2/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2025-06-13","Submitted applicatio via roster. FC"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./5514 N Big Spring St/3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised that the process to enroll provider is over the phone. TAT 60 calendar days. Call ref# Aby S 08/05/2025."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./5514 N Big Spring St/3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised that the process to enroll provider is over the phone. TAT 60 calendar days. Call ref# Aby S 08/05/2025."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-06-02","","","2025-06-24","Received email from PPHP (pphpprovidernetwork@pphealthplan.com) confirming provider is participating, linked to TIN/location, eff. 6/2/2025. PA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-06-02","","","2025-07-17","Received confirmation via email from Provider_Services_Shared.T8@90degreebenefits.com. Provider participating effective 6/2/25 ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-06-02","","","2025-07-17","Received confirmation via email from Provider_Services_Shared.T8@90degreebenefits.com. Provider participating effective 6/2/25 ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ 5514 N Big Spring St Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-06-02","","","2025-07-29","Received confirmation via email from Emily Starr, provider participating effective 6/2/2025. FC"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2025-06-02","","","2025-07-29","Received confirmation via email from Emily Starr, provider participating effective 6/2/2025. FC"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Enrollment Stopped","Enrollment Stopped","","","","2025-05-13","MCR enrollment was stopped, therefore RRMCR was stopped. MS"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-07-01","","","2025-07-21","Per the July SHP Validation report, provider is enrolled, linked to TIN/location, eff. 7/1/2025. PA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-08-20","1124826490","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/20/2025 for all locations. PIN is the NPI"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-08-20","1124826490","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/20/2025 for all locations. PIN is the NPI"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","No Value Specified","2025-09-09","","","2025-09-09","09/09/2025 per email CAQH Reattested-all information is correct and up to date-dvineyard"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","No Value Specified","2025-09-09","","","2025-09-09","09/09/2025 per email CAQH Reattested-all information is correct and up to date-dvineyard"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","Superior","Opt Out","Opt Out","","","","2025-06-13","Provider did not select this payor. PA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","1124826490","","2025-09-10","09/10/2025 AC: Per email response received from  Texas_CorCare@corvel.com on 08/26/2025, provider NPI# is on file for the provider and is credentialed effective 8/26/2025."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Resubmitted","","","","2025-08-25","08/25/2025 MQ: For Locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 6301 Andrews Hwy/ 616 N Main St./ 3490 E Yukon Rd. /5514 N Big Spring St/ Checked Texas Mutual's directory to check provider status but provider is not found."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Resubmitted","","","","2025-08-25","08/25/2025 MQ: For Locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 6301 Andrews Hwy/ 616 N Main St./ 3490 E Yukon Rd. /5514 N Big Spring St/ Checked Texas Mutual's directory to check provider status but provider is not found."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Enrollment Stopped","Enrollment Stopped","","","","2025-05-12","Client requested to not enroll with Medicare. MS"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Enrollment Stopped","Enrollment Stopped","","","","2025-05-12","Client requested to not enroll with Medicare. MS"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-06-02","","","2025-08-06","Received confirmation via phone call provider participating eff date 6/2/2025, spoke to Rachel (call ref# 1672166). FC"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-06-02","","","2025-08-06","Received confirmation via phone call provider participating eff date 6/2/2025, spoke to Rachel (call ref# 1672166). FC"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-07-15","","","2025-08-05","Received email from BSW confirming provider is par, linked to TIN/location, eff. 7/15/2025. PA."]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-06-02","","","2025-07-18","Received confirmation via email from Addella Yarnold, provider participating effective 6/2/2025. FC"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-06-02","","","2025-09-16","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 6/2/2025. ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-09-01","","","2025-09-30","Per Emma, the provider's effective date is 9/1/2025 ref#21352637-SG"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-06-13","1124826490","","2025-06-25","Welcome ltr rcvd. Effective 06/13/2025. Jen Videan"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-06-13","1124826490","","2025-06-25","Welcome ltr rcvd. Effective 06/13/2025. Jen Videan"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-06-02","","","2025-08-28","Received confirmation of provider enrollment effective 6/2/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-07-01","8824574","","2025-07-16","Received confirmation via email (roster) from Brandy Smith. Provider participating effective 7/1/25 ML"]
["Rachel Paige Tolbert, APRN-NP","1124826490","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-06-02","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 6/2/2025. ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2025-09-01"," 1639821564","","2025-08-27","Per noreply@mdstaff.com,  Congratulations – You have successfully completed the WorkWell, TX and Texas Star Network credentialing requirements.\n\nWe are pleased to let you know that you completed our credentialing requirements and that you will now be a participating member of WorkWell, TX and the Texas Star Network effective 09/01/2025. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-07-08","","","2025-08-15","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 7/8/25.  ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-07-08","","","2025-08-15","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 7/8/25.  ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-08-01","","","2025-08-28","Received confirmation via email from Mary Hana, provider participating eff date 8/1/2025. FC"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-09-19","09/19/2025 AC: For location: 616 N Main St/ 4705 Briarwood Ave/ 6301 Andrews Hwy/ 6950 Eastridge Rd./ 3490 E Yukon Rd./ 5514 N Big Spring St Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-08-15","","","2025-08-18","Received email confirming provider's participation with network under the TIN/Location effective 8/15/25 from hpdelegation@bswhealth.org. ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-04-07","Q01038626","","2025-05-29","Provider is linked. MS"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-04-07","Q01038626","","2025-05-29","Provider is linked. MS"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2025-07-08","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 7/8/2025. ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2025-07-08","","","2025-10-10","per email from Mindy provider eff 7/8/25-SG"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2025-07-08","","","2025-10-10","per email from Mindy provider eff 7/8/25-SG"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-07-01","3705997","","2025-08-18","Received confirmation via email from cssupport@cvty.us.com, provider partcipating as of 7/1/2025, provider id#3705997. FC"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2025-04-07","","","2025-05-13","Provider is active eff 4/7/25. MS"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-06-20","","","2025-06-30","Please see status updates under Alliance WC payor line. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-06-20","","","2025-06-30","Please see status updates under Alliance WC payor line. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025. Provider is enrolled in Ambetter (Commercial-EXchange). ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Add Info Submitted","","","","2025-08-18","Emailed Emily Starr, Lee Kinard, and Aleece Moerbe for update on network status. FC"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-07-08","","","2025-09-02",""]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-13","For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 6301 Andrews Hwy/ 616 N Main St./ 3490 E Yukon Rd./ 5514 N Big Spring St 08/05/2025 KN: Called Cigna@1-800-882-4462 and spk w/ Jessica. Per rep, provider is INN w/ TX but not link to Grp/TIN. Rep advised that TIN 47-3465832 is contracted under Ancillary Contract and Cigna does not add individual provider to Ancillary contract so there's no need to submit app for the provider and we can just bill claim under the Name of the Grp. Rep can't provide eff date of the Grp Ancillary Contract unless service address on their file is verified. Service Address we have is not on file and per rep, we need to add it to the Grp Ancillary Profile since we need to ensure that before we bill a claim, service address is added to the In Network location list of the Grp. Per rep, submit LOI and W9 Form through email intake_pdm@evernorth.com. Subject: 2 Letter Abbreviation of State, Group Name, TAX ID# (Make sure no dash on TAX ID), Concern. TAT is 30 cal days from received date. Callref: Jessica S 08/05/25"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-07-08","","","2025-08-04","Received email notification from Keandra Walker (kwalker@pphealthplan.com) confirming July 2025 roster has been processed. Provider is par, linked to TIN/location, eff. 7/8/2025. PA."]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-07-08","","","2025-08-04","Received email notification from Keandra Walker (kwalker@pphealthplan.com) confirming July 2025 roster has been processed. Provider is par, linked to TIN/location, eff. 7/8/2025. PA."]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-06-20","  1639821564","","2025-06-30","Welcome ltr rcvd. Effective 06/20/2025. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation of provider enrollment effective 7/8/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-07-01","","","2025-09-03","Received confirmation via phone call providefr participating eff 7/1/25 spoke to Shan call ref# 1709456. SG"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2025-07-08","","","2025-09-05","Received confirmation via online provider portal chat box (spoke with Demitra, ref # 05412953)  that provider is participating with network, effective 7/8/2025. ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","  1639821564","","2025-09-10","09/10/2025 MQ: Per email response received on 8/26/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is particpating under TIN and GROUP effective 8/26/2025 for all locations. PIN is the NPI."]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","  1639821564","","2025-09-10","09/10/2025 MQ: Per email response received on 8/26/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is particpating under TIN and GROUP effective 8/26/2025 for all locations. PIN is the NPI."]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-07-16","","","2025-07-28","Approval ltr rcvd. Effective 07/16/2025. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025.  ML"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-08-15","","","2025-08-15","08/15/2025 CAQH Reattested-updated COI policy number in Cactus and CAQH to match doc-dvineyard"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-07-01","","","2025-07-02","Received email confirmation from BCBSTX that the provider is participating, effective 7/1/2025, and is linked to TIN/locations. The provider is enrolled in the following networks, all effective 7/1/2025:\nBAV – Blue Advantage HMO\nBCA – BlueChoice PPO\nHME – Health Select\nHMO – Blue Essentials\nPMC – Medicare Advantage PPO. PA"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-07-01","","","2025-07-02","Received email confirmation from BCBSTX that the provider is participating, effective 7/1/2025, and is linked to TIN/locations. The provider is enrolled in the following networks, all effective 7/1/2025:\nBAV – Blue Advantage HMO\nBCA – BlueChoice PPO\nHME – Health Select\nHMO – Blue Essentials\nPMC – Medicare Advantage PPO. PA"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Add Info Submitted","","","","2025-08-18","Emailed Emily Starr, Lee Kinard, and Aleece Moerbe for update on network status. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2025-08-01","","","2025-08-28","Received confirmation via email from Mary Hana, provider participating eff date 8/1/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./5514 N Big Spring St/ 08/05/2025 KC: Called 800-882-4462 and spoke w/ Jaq A at Cigna. Stated provider is totally OON and not link to the tax id.To be innetwork/credentialed rep advised provider must reach out cigna to initiate the application over the phone/call.TAT 60 cal days.Call ref# Jaq A 08/05/2025."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./5514 N Big Spring St/ 08/05/2025 KC: Called 800-882-4462 and spoke w/ Jaq A at Cigna. Stated provider is totally OON and not link to the tax id.To be innetwork/credentialed rep advised provider must reach out cigna to initiate the application over the phone/call.TAT 60 cal days.Call ref# Jaq A 08/05/2025."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Locations effective 7/8/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Resubmitted","","","","2025-08-25","08/25/2025 MQ: For Locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 6301 Andrews Hwy/ 616 N Main St./ 3490 E Yukon Rd. /5514 N Big Spring St/ Checked Texas Mutual's directory to check provider status but provider is not found."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For locations: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ 5514 N Big Spring St Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For locations: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ 5514 N Big Spring St Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-06-20","1245067602","","2025-06-30","Please see status updates under Alliance WC payor line. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-07-01","","","2025-08-20","Received confirmation via phone call from Danielle Moore, provider participating eff date 7/1/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025. Provider is enrolled in Ambetter (Commercial-EXchange). ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2025-05-12","","","2025-05-12","Received email confirmation from BCBSTX that the provider is participating, effective 05/12/2025. The provider is enrolled in the following networks:\nBlue Choice PPO – 05/12/2025\nBlue Advantage HMO – 05/12/2025\nBlue Essentials HMO – 05/12/2025\nHealth Select – 05/12/2025\nMedicare Advantage PPO – 05/12/2025\nTriWest – 01/29/2025\nPAR – 09/18/2024\nPA."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025.  ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025.  ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","In Process","Payor Follow Up","","","","2025-08-15","Requested enrollment status via email, sent to  payor. ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-06-20","1245067602","","2025-06-30","Welcome ltr rcvd. Effective 06/20/2025. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-06-20","1245067602","","2025-06-30","Welcome ltr rcvd. Effective 06/20/2025. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-08-26","  1245067602","","2025-09-10","09/10/2025 MQ: Per email response received on 8/26/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/26/2025 for all locations. PIN is the NPI."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2025-07-08","","","2025-08-19","Received confirmation via email from Addella Yarnold, provider participating as of 7/8/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Enrollment Stopped","Enrollment Complete","2025-04-07","","","2025-05-13","Provider is linked to the group. The Client has requested to stop enrollment for the provider. mS"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation of provider enrollment effective 7/8/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2025-07-01","","","2025-09-03","Received confirmation via phone call providefr participating eff 7/1/25 spoke to Shan call ref# 1709456. SG"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-08-20","1245067602","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/20/2025 for all locations. PIN is the NPI."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-08-20","1245067602","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 08/20/2025 for all locations. PIN is the NPI."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all locations. PIN is the NPI."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2025-07-08","","","2025-08-04","Received email notification from Keandra Walker (kwalker@pphealthplan.com) confirming July 2025 roster has been processed. Provider is par, linked to TIN/location, eff. 7/8/2025. PA."]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-09-09","09/09/2025 CAQH Reattested per email-all information is correct and up to date-dvineyard"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-07-08","","","2025-09-02","Received confirmation via email from provider_services_shared.t8@90degreebenefits.com, provider participating eff 7/8/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2025-07-08","","","2025-09-02","Received confirmation via email from provider_services_shared.t8@90degreebenefits.com, provider participating eff 7/8/2025. FC"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2025-07-08","","","2025-08-15","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 7/8/25.  ML"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2025-07-08","","","2025-10-10","per email from Mindy provider eff 7/8/25-SG"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Enrollment Stopped","Enrollment Stopped","","","","2025-05-13","Medicare enrollment was stopped, so RRMCR was stopped as well. MS"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Enrollment Stopped","Enrollment Stopped","","","","2025-05-13","Medicare enrollment was stopped, so RRMCR was stopped as well. MS"]
["Margaret Elizabeth O'Neal, FNP","1245067602","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2025-08-15","","","2025-08-18","Received email confirming provider's participation with network under the TIN/Locations effective 8/15/25 from hpdelegation@bswhealth.org. ML"]
["Patrick Anthony Naeger, MD","1336703776","46-3131679","TX","Midland Texas Orthopedic Group Inc","First Health Coventry","In Process","Payor Follow Up","","","","2025-09-30","Per Day B., the provider is in network but cannot give an effective date yet, as the contract is not updated. He stated to call back in a week, ref#1748571-SG"]
["Patrick Anthony Naeger, MD","1336703776","46-3131679","TX","Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2025-08-04","","","2025-10-01","Per email from Brandy provider effective 8/4/25 PIN#2365930-SG"]
["Patrick Anthony Naeger, MD","1336703776","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicare","Participating","Add Info Submitted","2025-09-08","","","2025-09-30","Corrected the effective date on his TMHP application. Request # is 20781447. VA"]
["Sarai Avila Marks, APRN-NP","1619785656","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2025-07-08","","","2025-08-18","Received email confirming provider's participation on network under the TIN/Location effective 7/8/25 from LeNetrice Myart (lanetrice.myart@usamco.com). ML"]
["Sarai Avila Marks, APRN-NP","1619785656","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2025-07-08","","","2025-08-15","Per email from Karen Avalos (@kavalos@gh-mci.com), provider is participating in all locations effective 7/8/25.  ML"]
["Jigar Maheshkumar Rathod, MD","1164721742","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2025-08-01","","","2025-08-06","Per the August SHP Validation report, provider is enrolled, linked to TIN/location, eff. 8/1/2025. Provider is enrolled in Ambetter (Commercial-EXchange) and Ambetter Value. ML"]
["Jigar Maheshkumar Rathod, MD","1164721742","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2025-07-08","","","2025-08-28","Received confirmation of provider enrollment effective 7/8/2025 via email from Marcus Wester (mwester@humana.com). ML"]
["Tejaswi Bhari Thippeswamy, MD","1811189269","","TX","Midland Inpatient Medical Associates","Cigna","Participating","Enrollment Complete","2025-07-01","","","2025-09-04","Received email from CIGNA's email portal stating providers application was completed with effective date of 07/01/2025 ID#8687831. MR"]
["Nina Ezinne Nwoko, APRN-NP","1689261679","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2025-10-01","","","2025-10-06","Per the October SHP Validation report, provider is enrolled, linked to TIN/location, eff. 10/01/2025.  ML"]
["Emma Aaye Zheng, APRN-NP","1861971699","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-10-02","Railroad Medicare has been approved. VA"]
["Annalee Abrigo Mora, MD","1114292398","47-5554737","TX","","Amerigroup","In Process","Application Submitted","","","","2025-09-15","Application submitted via delegated roster. SG"]
["Annalee Abrigo Mora, MD","1114292398","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2025-10-01","","","2025-10-06","Per the October SHP Validation report, provider is enrolled, linked to TIN/location, eff. 10/01/2025.  ML"]
["Annalee Abrigo Mora, MD","1114292398","47-5554737","TX","","Omni PPO","In Process","Application Submitted","","","","2025-09-15","Application submitted via delegated roster. SG"]
["Annalee Abrigo Mora, MD","1114292398","47-5554737","TX","","Caprock (CapStar)","In Process","Application Submitted","","","","2025-09-15","Application submitted via delegated roster. SG"]
["Annalee Abrigo Mora, MD","1114292398","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","In Process","Follow Up Complete","","","","2025-10-13","Requested network status via online chat box (Spoke with Macey, ref #05489652). Enrollment is still pending. ML"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2025-08-15","","","2025-09-24"," Railroad Medicare has been approved effective 8/15/2025 VA"]
["Lindsay Elizabeth Baty, APRN-NP","1760154256","47-3465832","TX","","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2025-08-27","Submitted the Roster to Brandhi Wilson @ brandhi_wilson-Woods@corvel.com for Corvel. VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2025-10-02","Broadspire Roster submitted to updates@primehealthservices.com VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2025-10-02","Submitted Corvel Roster to agie_anyanya@corvel.com and texas_corcare@corvel.com. VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Application Submitted","","","","2025-10-06","Submitted application VIA email @TXMAContracting@Cigna.com <txmacontracting@cigna.com>. MR"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","tx","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-10-02","Railroad Medicare has been approved. VA"]
["Krystal Rae Estrada, APRN-NP","1467334573","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2025-10-02","Railroad Medicare has been approved. VA"]
["Michael Anthony Gonzales, APRN-NP","1154053940","","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2025-10-02","Submitted Corvel Roster to agie_anyanya@corvel.com and texas_corcare@corvel.com. VA"]
["Michael Anthony Gonzales, APRN-NP","1154053940","","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2025-10-02","Broadspire Roster has been submitted to updates@primehealthservices.com VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2025-10-02","Submitted Corvel Roster to agie_anyanya@corvel.com and texas_corcare@corvel.com. VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","","","","2025-09-19","CAQH profile attestation completed by another user. All information correct/up to date. Next attestation due on 1/16/2026. M"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","","","","2025-09-19","CAQH profile attestation completed by another user. All information correct/up to date. Next attestation due on 1/16/2026. M"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2025-10-02","Roster submitted for Broadspire to updates@primehealthservices.com VA"]
["Paige Linsey Anderson, APRN-NP","1679013585","","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2025-10-02","Roster submitted for Broadspire to updates@primehealthservices.com VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2025-10-02","Submitted Corvel Roster to agie_anyanya@corvel.com and texas_corcare@corvel.com. VA"]
["Natalie Danielle Franco, APRN-NP","1275410649","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2025-10-02","Broadspire Roster submitted to updates@primehealthservices.com VA"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","2025-09-23","","","","CAQH reattestation complete & profile up to date - Next attestation due on 1/21/2026. ML"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2025-10-02","Broadspire Roster submitted to updates@primehealthservices.com VA"]
["Kailani A Greenwood, PA","1275171423","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2025-10-02","Broadspire Roster submitted to updates@primehealthservices.com VA"]
["James H Barnett, MD","1356484497","27-4061759","TX","Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2021-10-06","136698110","356723201","2021-11-03","11/3/2021 Per TMHP website provider's revalidation has been completed effective 10/06/2021 with the next revalidation date being 11/23/2023.  DCannon"]
["James H Barnett, MD","1356484497","27-4061759","TX","","Humana","Participating","Enrollment Complete","2012-11-09","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 11/9/2012.  DCannon"]
["James H Barnett, MD","1356484497","27-4061759","TX","Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2010-12-29","1356484497","","2020-06-29","06/29/2020 - confirmed that IMS is effective, therefore this enrollment is also effective - Stacey Hudak"]
["James H Barnett, MD","1356484497","27-4061759","TX","Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2015-03-24","","","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 3/24/2015.  DCannon"]
["James H Barnett, MD","1356484497","27-4061759","TX","","First Health Coventry","Participating","Application Resubmitted","2023-02-01","3649611","","2025-01-15","Application resubmitted via delegated roster. AS"]
["James H Barnett, MD","1356484497","27-4061759","TX","Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","","","","2024-08-21","TMHP Revalidation Approval Ltr rcvd. Jen Videan"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","Pankaj N. Patel, MD PA","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"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","Pankaj N. Patel, MD PA","Caprock (CapStar)","Participating","Add Info Submitted","2012-03-01","1124009766","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","Pankaj N. Patel, MD PA","HealthSmart PPO","Participating","Add Info Submitted","2012-01-01","1124009766","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","Pankaj N. Patel, MD PA","First Health Coventry","Participating","Add Info Submitted","2008-09-01","1124009766","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["John M McKenna, MD","1225170103","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2021-12-01","Q00181145","CE1588","2021-12-30","12/30/2021 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00181145 - effective 12/1/2021.  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","Premier Family Care, Inc","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","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","","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."]
["John M McKenna, MD","1225170103","75-2656723","TX","","First Health Coventry","Participating","Re-Credentialing","2021-11-15","1902363","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["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","","Multiplan","Participating","Re-Credentialing","2021-12-15","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","","Caprock (CapStar)","Participating","Re-Credentialing","2021-12-06","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD","1225170103","75-2656723","TX","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 M McKenna, MD","1225170103","75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-01-22","8020391","","2021-11-25","11/25/21 received letter from pdmcogz@cigna.com, enrollment complete. PID 8020391 eff 1/22/2022"]
["Michael J Dragun, MD","1679574099","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-08-30","Received confirmation via email from German Aviles provider participating eff date 7/1/2024. FC"]
["Michael J Dragun, MD","1679574099","75-2656723","TX","Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2025-02-01","","","2025-02-05","Received email from Scarlett Abigail. Provider is TW eff. 2/1/25. PA."]
["Michael J Dragun, MD","1679574099","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Mrunal C Patel, MD","1528000734","74-2348334","TX","Permian Gastroenterology PA","Cigna","Participating","Enrollment Complete","2010-10-21","1528000734","","2020-04-22","04/22/2020--SW Sharon of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 10/21/2010. Location is on file. Call ref# Sharon4202020\ncopied note from spreadsheet-tisha rader"]
["Mrunal C Patel, MD","1528000734","74-2348334","TX","Permian Gastroenterology PA","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-29","1528000734","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with ALL products (except Medicaid) with this TIN/Service Location- Stacey Hudak"]
["Willie Clyde Watson, III, MD","1659366433","75-2133441","TX","Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete","2002-11-15","1659366433","752133441","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Willie Clyde Watson, III, MD","1659366433","75-2133441","TX","Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1902473","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2008 PID # 1902473\ntisha rader"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","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","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","75-6000608","TX","","HealthSmart PPO","Participating","Add Info Submitted","2021-01-07","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-29","1518951342","","2024-07-05","Per michelle.killough@pswca.org, 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"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","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","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main st eff. 3/1/2024\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd & 4705 Briarwood Ave eff. 6/12/2023. AS"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","City of Midland Health Department","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"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","City of Midland Health Department","Caprock (CapStar)","Participating","Add Info Submitted","2021-01-07","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-01","","","2024-07-04","7/4/2024 provider participating as of 2/1/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-10-16","No updates are needed at the individual level for RR MCR when adding a new location unless that location will be updated to the primary location. MS"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","","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"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 9/13/2024..  PA."]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-12-03","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 12/03/2024. PA."]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-02",""]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2024-12-03","002438204","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff. 12/03/2024.  PA."]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-06-01","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 06/01/2023. PA"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2021-08-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","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","WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-01","1518951342","","2024-02-16","Per Michelle Killough @ Alliance WC provider is effective 12/01/2023.  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"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","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"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-07-26","Q00177598","DX4335","2021-12-08","12/8/2021 Rcvd RR Medicare PTAN Approval letter instantly.  RR Medicare PTAN#  Q00177598 - effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","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","WesTex Urgent Care, PLLC","CAQH","Delegated - Third Party","CAQH Reattested","2025-07-31","","","2025-07-31","07/31/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Delegated - Third Party","CAQH Reattested","2025-07-31","","","2025-07-31","07/31/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-18","Received email confirmation from PPHP, provider is linked to the location/TIN, eff. 7/11/2024. PA."]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/20/2023 for all locations. PIN is the NPI."]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2024-12-03","002438204","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff. 12/03/2024.  PA."]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-08-01","","","2025-08-11","08/05/2025 MP: Called 1-800-882-4462 and spoke w Grace at Cigna. Stated provider is PAR with GRP and TIN effective 08/01/2023. PIN is 9800227. Loc on file. Call ref Grace V. 08/05/2025"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","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","47-3465832","TX","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"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","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","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-02-02",""]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-01-07","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff.  1/07/2021. PA."]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","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","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-01","1518951342","","2023-12-18","See Alliance WC payor line for details. Jen Videan"]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-08-11","","","2024-03-22","Per BCBSTX roster, provider listed PAR, effective 8/11/2021, participating with the following networks: Blue Advantage HMO, \nBlueChoice PPO, Health Select, Blue Essentials HMO, and Medicare Advantage\nPPO. PA"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Debbie P Reese, MD","1629074984","75-2182177","TX","Debbie P. Reese, MD PA","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"]
["Debbie P Reese, MD","1629074984","75-2133441","TX","Midland Pediatric Associates, PLLC","Aetna","Participating","Re-Credentialing","2019-01-01","1629074984","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Debbie P Reese, MD","1629074984","75-2182177","TX","Debbie P. Reese, MD PA","Cigna","Participating","Enrollment Complete","2023-12-11","9750907","","2024-01-02","Received confirmation of approval. MS"]
["Debbie P Reese, MD","1629074984","75-2182177","TX","Debbie P. Reese, MD PA","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-17",""]
["Donald W Floyd, MD","1942216122","46-0950925","TX","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","Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","2025-06-18","1942216122","","2025-06-23","Approval ltr rcvd. Effective 06/18/2025. Jen Videan"]
["Donald W Floyd, MD","1942216122","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","Enrollment on Hold","Enrollment on Hold","","","","2025-09-16","Pending surrogacy for MCR to confirm RR enrollment. Jen Videan"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","Rail Road Medicare","Participating","Enrollment Complete","2001-08-01","P02417357","CI6074","2020-08-28","08/28/2020 - moved to completed status after finding EFF letter in the payer portal - Stacey Hudak"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","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","Permian Gastroenterology PA","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."]
["Govind B Patel, MD","1073555249","74-2348334","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2012-03-01","1073555249","","","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","CAQH","Participating","CAQH Reattested","2025-08-06","10594793","","2025-08-06","08/06/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Govind B Patel, MD","1073555249","74-2348334","TX","Permian Gastroenterology PA","Amerigroup","Participating","Application Resubmitted","2013-03-23","1073555249","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Govind B Patel, MD","1073555249","74-2348334","TX","","Humana","Participating","Enrollment Complete","2013-09-15","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/15/2013.  DCannon"]
["John C Dean, MD","1013923291","46-3131679","TX","Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["John C Dean, MD","1013923291","46-3131679","TX","Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2016-10-18","1013923291","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["John C Dean, MD","1013923291","46-3131679","TX","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 C Dean, MD","1013923291","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","119245205","331090601","2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Shylesh R Ganta, MD","1811900657","20-8658501","TX","Shylesh Ganta, MD, PA","CAQH","Active","CAQH Reattested","2025-09-15","11192078","","2025-09-15","09/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Shylesh R Ganta, MD","1811900657","20-8658501","TX","Shylesh Ganta, MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-01","1811900657","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Shylesh R Ganta, MD","1811900657","20-8658501","TX","Shylesh Ganta, MD, PA","Aetna","Participating","Enrollment Complete","2020-03-12","","","2024-08-27","As per Anj R (call ref# 62012556) provider participating as of 3/1/2020, listed as PCP. FC"]
["Bhuvana Balasekaran, MD","1770564080","46-1602172","TX","Bhuvana Balasekaran, MD PA","TriWest HC Alliance","Active","Payor Follow Up","2020-03-20","1770564080","","2025-06-05","06.03.2025 MG: 1st Attempt - Verification request has been emailed to gfitzpatrick@TriWest.com to verify provider credentialing status. An email response received on the same day saying rep is not the correct contact for this request and advised to utilize their Provider Directory to verify if these groups are in network yet or send an email to providercontracting@triwest.com Verification request has been emailed to providercontracting@triwest.com to verify provider credentialing status."]
["Eric J Venegas, MD","1760485502","75-2930500","TX","Eric J. Venegas, MD, PA","Rail Road Medicare","Participating","Enrollment Complete","2001-07-15","P00376959","","2020-09-28","09/28/2020 - signed onto site and confirmed effective info  _Stacey Hudak"]
["Eric J Venegas, MD","1760485502","75-2930500","TX","Eric J. Venegas, MD, PA","Amerigroup","Participating","Enrollment Complete","2012-03-01","10016928","","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 3/1/2012, MEDICARE - eff 8/1/2012, C-SNP - eff 1/1/2017, OTHER - eff 1/1/2021, OTHER - eff 1/1/2020,  PLUS - eff 3/1/2012, Star_Kids - eff 11/1/2016.  DCannon"]
["Eric J Venegas, MD","1760485502","75-2930500","TX","Eric J. Venegas, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1760485502","","2020-07-01","07/01/2020 - Rec'd confirmation from the payer that this provider is EFF - Stacey Hudak"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2017-03-17","2185555","","2020-06-08","06/08/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Application Resubmitted","2002-10-01","1295724698","Multiple Group Affiliations","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2011-09-01","1295724698","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 09/01/2011. – Archie Candiasan"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1295724698","","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"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","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"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Application Resubmitted","2011-02-01","1295724698","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1295724698","","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"]
["Dario Beltran, MD","1912100850","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-04-03","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 4/3/2020.  DCannon"]
["Dario Beltran, MD","1912100850","75-2656723","TX","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","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"]
["P Douglas Cochran, MD","1316026396","20-0212181","TX","P. Douglas Cochran, MD, PA","Aetna","Participating","Enrollment Complete","2023-05-01","","","2023-05-31","05.31.2023 S/W Ria of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 05/01/2023. Provider ID 7795370, Payer ID 60054 and Recredentialing date is 05/01/2026. Service location is on file. Call ref#:6149191218. - Danico Gabriel Melendres"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2016-02-09","1912991084","","2024-02-16","Per Michelle Killough @ Alliance WC provider is effective 02/19/2016.  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"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  PID # 2230880.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  PID # 2230880.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main st eff 10/4/2024\n6301 Andrews Hwy eff 5/6/2024\n6950 Eastridge Ave & 4705 Briarwood Ave eff. 6/12/2023. AS"]
["Terry L Beck, MD","1912991084","47-3465832","TX","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","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","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","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2016-02-09","1912991084","","2024-11-14","Per Michelle Killough at michelle.killough@pswca.org location has been added to group profile. 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"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. loc is on file. PIN is the NPI."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Payor Follow Up","","","","2024-04-30","Sent email to Multiplan rep Marcie Havens (marcie.havens@multiplan.com) requesting enrollment status update. PA."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2020-07-01","","","2024-07-19","Received roster from HP Delegation; provider is shown linked to TIN/locations, eff: 07/01/2020. PA."]
["Terry L Beck, MD","1912991084","47-3465832","TX","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","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Terry L Beck, MD","1912991084","47-3465832","TX","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 6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-01-01","","","2024-07-29","Received product roster. Provider is linked to TIN & location, eff.  01/01/2020. PA."]
["Terry L Beck, MD","1912991084","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2015-09-01","2230880","","2023-09-22","09.22.2023 S/W Bridgett of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 09/01/2015. Provider ID 2230880. Service location is on file. Call ref#:764027. - Danico Gabriel Melendres"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-10-01","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2015-05-09","","","2024-02-22","Re-Cred has been approved. MS"]
["Terry L Beck, MD","1912991084","47-3465832","TX","","Medicare","Participating","Enrollment Complete","2015-05-09","","","2025-03-21","Proivider was added to PTAN 6P6053. MS"]
["Terry L Beck, MD","1912991084","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-15","","","2025-09-15","09/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Terry L Beck, MD","1912991084","47-3465832","tx","","Aetna","Participating","Enrollment Complete","2023-10-02","4417046","","2023-10-19","10.16.2023 S/W Glen of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective on 10/02/2023. No next recredentialing date available. PIN: 4417046. Servicing location is on file. Payer# 60054. Call ref# 6166852878. - Willie Ravas"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-05-01","","","2024-05-09","Received email from Marina Martinez of USA MCO, provider is PAR and 616 Main St location linked, eff. 05/01/2024."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024.."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-06-14","6/14/2023 Add new locations - 4705 Briarwood Ave, 6950 Eastridge Rd. and 6301 Andrews Hwy.   DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","","First Health Coventry","Participating","Enrollment Complete","2015-09-15","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 09/15/2015 and linked to 616 Main St. location. PA."]
["Terry L Beck, MD","1912991084","47-3465832","TX","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","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location confirmed effective 10/9/2023. MS"]
["Terry L Beck, MD","1912991084","47-3465832","tx","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","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2016-02-19","1912991084","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Terry L Beck, MD","1912991084","47-3465832","TX","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","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-12","08.06.2025 KF: Called Cigna @ 1-800-882-4462 and spoke with Paul. Per rep, provider is in network under individual contract and OON under the grp. Per rep, the grp is under ancillary contract. To be in network, rep advised to send an email to cred team at psscentral@cigna.com. TAT is 60 cal days. Call ref# Paul C08062025"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2015-09-01","","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/1/2015. FC"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2015-08-28","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 8/28/2015.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","","IMS","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Terry L Beck, MD","1912991084","47-3465832","TX","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","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"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","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"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","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","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","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-09-12","3714369","","2022-11-08","11/8/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 9/12/2022.  PID # 3714369.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Wellcare","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"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","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","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","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-09-12","","","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 9/12/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","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","Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2022-10-10","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-08-14","","","2025-08-28","CAQH profile/ COI updated next attestation due 12/26/25 SG"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted","2022-09-12","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","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","Vincent P. Rascon","Omni PPO","Participating","Re-Credentialing","2012-01-01","1346236924","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Vincent P Rascon, DPM","1346236924","91-1559006","TX","Vincent P. Rascon","United Health Care","Participating","Enrollment Complete","2006-12-15","1017086","","2020-06-08","06/08/2020 - Rec'd email stating this provider/service location are EFF 12/15/2006 - under provider ID# 1017086 - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Cigna","Participating","Enrollment Complete","2011-03-09","1730181389","","2020-08-26","08/26/2020 - moved to completed status after reviewing foll up complete note - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Multiplan","Participating","Enrollment Complete","2021-09-02","1730181389","","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"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","Permian Physician Services","Medicare","Participating","Enrollment Complete","2021-01-01","1M9652","","2021-04-27","4/26/2021 Per email confirmation received from Stacy Salazar, provider has been assigned PTAN 1M9652 under group effective 1/1/2021. KFrazier"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","Permian Physician Services","Medicaid","Participating","Enrollment Complete","2021-01-01","137280711","205408201","2021-04-14","4/14/2021 Rcvd TMHP Approval letter from Stacy Salazar that provider has been linked to Permian Physician Services TMHP group #.  TPI # 137280711 effective 1/1/2021"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","Permian Physician Services","Wellmed","Participating","Enrollment Complete","2022-01-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Sedgwick","Participating","Enrollment Complete","2024-05-21","1730181389","751997880","2024-05-24","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","Permian Physician Services","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","Andrews County Hospital District","Medicaid","Facility Enrollment","Facility Enrollment","","112273103","","2020-09-23"," 09/23/2020 - Rec'd email from the clinic with the group RHC TPI# 112273103.  Moved to effective status to bring payer line to a desired status. THIS IS A FACILITY ENROLLMENT - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","","United Health Care","Participating","Enrollment Complete","2022-01-12","001199099","","2022-02-09","2/9/2022 Received email from united_healthcare_provider_operations@uhc.com, provider/group updates are complete. PID 001199099. Reference number PR-6309606. Sent email to network services requesting eff date. Cbankston"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","Andrews County Hospital District","Superior","Participating","Enrollment Complete","2020-10-01","1730181389","","2020-10-02","10/02/2020 - rec'd email from the payer confirming this provider has been added to the primed delegation - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","Permian Physician Services","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-17","For Locations: 700 Hospital Drive/704 Hospital Drive/07/17/2025 MQ: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Medicare","Facility Enrollment","Facility Enrollment","","RHC Part A Only","","2020-09-01","09/01/2020 - RHC - Part A Only. Provider cannot be enrolled under the group, as this would be billed under the facility - Stacey Hudak"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","","IMS","Participating","Add Info Submitted","2001-01-15","1316965403","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","Rajanikant P. Pandya","Multiplan","Participating","Add Info Submitted","1999-09-23","1316965403","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","Rajanikant P. Pandya","Medicare","Participating","Enrollment Complete","1995-04-03","0059AS","N/A - no group enrollment for Medicare","2020-03-10","03/10/2020 - Signed into PECOS and found active/EFF individual provider enrollment only. No reassignment to group - Stacey Hudak"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","Rajanikant P. Pandya","Scott&White (First Care)","Participating","Enrollment Complete","2016-06-01","1316965403","","2020-04-16","04/16/2020 - Rec'd spreadsheet from the payer confirming this provider is EFF with all products under the PRIMED DELEGATED agreement at this TIN/Service Location. - Stacey Hudak"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","C Vallie CFNP Limited Partnership","Superior","Participating","Enrollment Complete","2021-03-01","","","2021-03-09","3/9/2021 Rcvd notification from Delegated payor that provider is participting under TIN and at location effective 3/1/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-10-06","","","2025-08-11","08/05/2025 MP: Called 1-800-353-1232 and spoke w Melanie at Aetna. Stated provider is PAR with GRP and TIN effective 10/06/2024. PIN is 7900545. Loc on file. Call ref 256067833."]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","C Vallie CFNP Limited Partnership","USA PPO","Participating","Enrollment Complete","2021-02-08","","","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 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","C Vallie CFNP Limited Partnership","Amerigroup","Participating","Enrollment Complete","2021-02-08","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2024-10-06","Q00921741","CE1588","2025-01-03","Provider is active. MS"]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","Joseph Damiani","Omni PPO","Participating","Re-Credentialing","2014-10-31","1093821274","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","Joseph Damiani","Texas Mutual","Participating","Enrollment Complete","2020-06-03","","","2025-08-19","08/15/2025 MQ: Checked Texas Mutual's directory to check provider status but provider is not found."]
["Anand C Reddy, MD","1780892760","26-3789190","TX","Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-02-28","Received email from BSW HP Region,  confirming provider is linked to TIN/location combination, eff.  11/01//2024. PA. Provider participating in BSWH  Employee Network Tier 1, Medicare Advantage, BSW Premier HMO, BSW Premier PPO. PA."]
["Anand C Reddy, MD","1780892760","26-3789190","TX","","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. PA."]
["Anand C Reddy, MD","1780892760","26-3789190","TX","Permian Physician Services","Aetna","Participating","Enrollment Complete","","","","2025-08-11","08/05/2025 MP: Called 1-800-353-1232 and spoke w Maria at Aetna. Stated provider is PAR with GRP and TIN effective 01/25/2024. PIN is 9382732. Loc on file. Call ref 256054103."]
["Anand C Reddy, MD","1780892760","81-3411343","TX","Permian Basin Kidney Center Inc","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Anand C Reddy, MD","1780892760","81-3411343","TX","Permian Basin Kidney Center Inc","Omni PPO","Participating","Enrollment Complete","2019-05-01","1780892760","","2020-06-26",""]
["Anand C Reddy, MD","1780892760","26-3789190","TX","","IMS","Participating","Enrollment Complete","2024-01-25","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 1/25/2024. AS"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","","Medicaid","Participating","Enrollment Complete","2019-05-01","296523803","397597101","2020-05-01","05/01/2020 - Rec'd confirmation of this information from the providers staff - Stacey Hudak"]
["Anand C Reddy, MD","1780892760","26-3789190","TX","Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2024-09-13","","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 9/13/2024. AS"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","Permian Basin Kidney Center Inc","United Health Care","Participating","Enrollment Complete","2019-05-01","3334870","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","","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"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2024-09-01","","","2024-09-27","Received email confirmation provider is par and linked to TIN/location, eff. 9/1/2024.  PA"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2024-08-05","","","2024-09-18","Received email confirmation from Karen Avalos stating August 2024 roster has been processed. Provider is par and linked to TIN/Location, eff. 8/5/2024. PA."]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2024-08-05","","","2024-10-01","Received confirmation via email, provider participating as of 8/5/2024. FC"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","IMS","Participating","Enrollment Complete","2024-08-05","","","2024-10-03","Received confirmation via phone call from German Aviles, provider participating as of 8/5/2024. FC"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2024-09-01","","","2024-09-27","Received email confirmation provider is par and linked to TIN/location, eff. 9/1/2024.  PA"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2024-08-05","","","2024-10-07","Received confirmation via email, provider participating as of 8/5/2024. FC"]
["Melissa D Alworth, DO","1942454525","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2024-10-01","6Y9788","0008AH","2024-10-08","Confirmed provider is linked. MS"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","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"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","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","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","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."]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2012-10-15","","","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"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Add Info Submitted","2012-10-15","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","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"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2012-10-29","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 10/29/2012.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-10-13","10/13/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","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"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","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"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","Permian Cardiology Inc.","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-10","5/10/2023 Tricare Prime panel is closed and currently not accepting requests to join the network.  DCannon"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","Permian Cardiology 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"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2023-05-08","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/8/2023.  DCannon"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","Permian Cardiology Inc.","Multiplan","Participating","Add Info Submitted","2023-05-01","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","Permian Cardiology 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"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-04-26","","","2021-09-15","9/15/2021 Received roster from Multiplan listing provider as PAR under group TIN/location effective 4/26/2017.  DCannon"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","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"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","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","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","Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2013-09-09","","","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 9/9/2013.  DCannon"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-09-17","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/17/2020.  DCannon"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","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","Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2016-01-11","1336304120","","2020-08-19","8/19/2020 - 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 under: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-01","","","2021-12-08","12/8/21 Per provider portal, provider is linked to this location. Cbankston"]
["Maung K Hlaing, MD","1306167309","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1306167309","","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"]
["Maung K Hlaing, MD","1306167309","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-06-01","1306167309","","2020-03-10","03/10/2020 - Rec'd email response from the payer stating \"Good afternoon, I show the provider being linked to the TIN for that location. Provider is also linked to 4214 Andrews Hwy.\" - Stacey Hudak"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","Leo Villaroman, MD, PA","CAQH","Participating","CAQH Reattested","2025-08-14","","","2025-08-14","08/14/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","IMS","Participating","Enrollment Complete","2023-01-09","","","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 1/9/2023.   DCannon"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","Cigna","Participating","Enrollment Complete","2023-09-19","","","2025-08-11","08/05/2025 KC: Called 800-882-4462 and spoke w/ Jaq A at Cigna. Stated provider is innetwork and link to the tax id .Provider id# 5302942.Physical location is onfile.Call ref# Jaq A 08/05/2025."]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","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","","Galaxy Health","Participating","Enrollment Complete","2023-01-09","","","2023-03-09","3/9/2023 Per email rcvd from Karen Avalos at Galaxy, January monthly roster has been completed.  Provider is PAR and linked to group effective 1/9/2023.  DCannon"]
["Leela K Lella, MD","1306162557","27-4061759","TX","","Humana","Participating","Enrollment Complete","2020-01-01","1306162557","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Leela K Lella, MD","1306162557","27-4061759","TX","","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-06","Emailed tricareproviderinquiries@triwest.com for status. Jen Videan"]
["Leela K Lella, MD","1306162557","27-4061759","TX","Permian Cardiology Inc.","HealthSmart PPO","Participating","Add Info Submitted","2018-06-19","1306162557","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Leela K Lella, MD","1306162557","27-4061759","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2020-03-01","1306162557","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Leela K Lella, MD","1306162557","27-4061759","TX","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"]
["Leela K Lella, MD","1306162557","27-4061759","TX","Permian Cardiology Inc.","Multiplan","Participating","Add Info Submitted","2018-06-19","1306162557","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Asif Ali Khan Ansari, MD","1528299872","81-3411343","TX","","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"]
["Asif Ali Khan Ansari, MD","1528299872","81-3411343","TX","Permian Basin Kidney Center Inc","USA PPO","Participating","Enrollment Complete","2020-04-03","","","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 04/03/2020.  DCannon"]
["Asif Ali Khan Ansari, MD","1528299872","26-3789190","TX","Permian Physician Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-12","Location is not Tricare certified, and the panel is closed to new locations. MS"]
["Asif Ali Khan Ansari, MD","1528299872","81-3411343","TX","","Triwest VA","Participating","Enrollment Complete","2021-05-15","","","2021-05-31","5/31/2021 Received forwarded email from Rebecca Pontaski with confirmation provider is participating with VACCN (TriWest) effective 5/15/2021. KFrazier"]
["Asif Ali Khan Ansari, MD","1528299872","26-3789190","TX","","Cigna","Participating","Enrollment Complete","2024-07-31","5099421","","2025-09-05","Per PDMCOGZ@evernorth.com, TIN is loaded under the provider with effective date of 07/31/2024. Jen Videan"]
["Asif Ali Khan Ansari, MD","1528299872","81-3411343","tx","Permian Basin Kidney Center Inc","Amerigroup","Participating","Enrollment Complete","2020-03-18","","","2023-08-31","8/31/2023 Per Amerigroup portal provider has been added to new location.  Provider effective date 3/18/2020.  DCannon"]
["Asif Ali Khan Ansari, MD","1528299872","81-3411343","TX","","Humana","Participating","Enrollment Complete","2019-06-04","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 6/4/2019.  DCannon"]
["Asif Ali Khan Ansari, MD","1528299872","26-3789190","TX","","United Health Care","Participating","Enrollment Complete","2024-10-13","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 10/13/2024.  PA"]
["Asif Ali Khan Ansari, MD","1528299872","81-3411343","TX","Permian Basin Kidney Center Inc","Wellmed","Participating","Enrollment Complete","2023-03-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/24/2023.  DCannon"]
["Asif Ali Khan Ansari, MD","1528299872","26-3789190","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","","","2025-03-12","Received confirmation via email from payor, provider participating as of 9/1/2019. FC"]
["Asif Ali Khan Ansari, MD","1528299872","81-3411343","tx","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"]
["Audrey N Mangwiro, MD","1346265162","47-5554737","TX","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-09-15","","","2025-09-15","09/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Audrey N Mangwiro, MD","1346265162","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 11/4/2024. FC"]
["Alaaedin Alhomosh, MD","1063709913","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-12-12","5715174","","2025-08-12","08/06/2025 TE: Called 1-800-882-4462 and spoke with Jay at CIGNA. Provider is in network with the TIN effective 12/12/2024. Location is on file. PIN 5715174. Call ref# Jay 08/06/2025"]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2021-04-18","5271958","","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 4/18/2021 and assigned provider ID 5271958. KFrazier"]
["Alaaedin Alhomosh, MD","1063709913","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Add Info Submitted","2024-11-09","","","2025-06-24","Sent request to update taxonomoy code on 6/13/2025. Received confirmation request was processed from PPHP (pphpprovidernetwork@pphealthplan.com), on 6/19/2025. PA."]
["Alaaedin Alhomosh, MD","1063709913","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2025-04-15","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 4/15/2025. PA."]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2016-11-27","338869610","364596201","2020-12-31","12/31/2020 Confirmed provider is participating and assigned TPI 338869610 under group. Revalidation due 12/21/2022. KFrazier"]
["Nancy Ny Asamoa, MD","1023135639","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2021-03-15","","","2025-01-30","Received confirmation via email from Caprock, provider participating as of 3/15/2021. FC"]
["Nancy Ny Asamoa, MD","1023135639","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1295109510","","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"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-01-11","","","2020-10-23","10/23/2020 Provider is participating with TriCare Prime; therefore, remains certified as a non-network effective 1/11/2018. Kimberly Frazier"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-04-26","1295109510","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 4-26-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","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","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-04-26","","","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 4/26/2016.  DCannon"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","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","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2024-02-13","Ste. 200 is not a Prime Credentialed location. Panel is closed. MS"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","Midland Texas Orthopedic Group Inc","Humana","Participating","Confirm Par Status","2019-08-01","1215254156","","2025-02-11","Received email confirmation provider is par, linked to TIN & location, eff. 08/01/2019. PA"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","Midland Texas Orthopedic Group Inc","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2020-01-01","1215254156","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2016-08-15","P02008203","DU5783","2020-03-10","03/10/2020 - Found EFF information through payer site - Stacey Hudak"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2025-09-09","","","2025-09-09","09/09/2025 per email CAQH Reattested-updated TX Lic and  uploaded doc-dvineyard"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","Permian Cardiology Inc.","Multiplan","Participating","Application Resubmitted","2023-02-01","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","Permian Cardiology Inc.","IMS","Participating","Application Resubmitted","2023-05-30","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","Premier Family Care, Inc","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","","Caprock (CapStar)","Participating","Enrollment Complete","2015-10-15","1770883191","","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"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2015-12-01","1770883191","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Also showing 01/01/2020 and 11/1/16 and 1/1/17 as effective dates.  Tisha Rader"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2018-04-14","","","2020-12-21","12/21/2020 Upon review of the Self-Service portal, provider has been fully re-credentialed as it's listed as 'complete'. KFrazier"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","","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","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","384181902","079837301","2024-02-21","Rcvd revalidation approval letter. Jen Videan"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2018-07-31","1275044422","752656723","2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-02-13","1275044422","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2018-08-01","3159807","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2018 PID # 3159807-tisha rader"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","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","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2015-07-11","1013990761","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2020-04-03","","","2022-04-09","4/09/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 4/3/2020.  DCannon"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","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"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","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","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2011-09-01","1013990761","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","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"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","Rail Road Medicare","Participating","Enrollment Complete","2003-12-15","P02452801","DC8592","2020-07-20","07/20/2020 - moved to completed status and uploaded effective info from payer site - Stacey Hudak"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2015-12-08","","","2021-11-18",""]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","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","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Re-Credentialing","2021-04-13","","","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","Midland Inpatient Medical Association","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Karen Ward, APRN-NP, RNFA","1790831493","47-5554737","TX","","Superior","Participating","Re-Credentialing","2021-05-01","","","2024-02-19","2/19/2024 - submitted recred status via delegated monthly roster on 02/15/2024. PA."]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","IMS","Participating","Application Resubmitted","2017-05-01","1598976011","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","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"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2014-07-29","1598976011","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 7/29/2014 - Jesriel Segovia"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Application Resubmitted","2014-08-01","1598976011","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-07-07","3218941","","2021-07-09","7/9/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 7/7/2021 with assigned provider ID 3218941. KFrazier"]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-08-01","1437175163","","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"]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","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"]
["Frank O McGehee, IV, MD","1134151756","27-0950535","TX","","Humana","Participating","Enrollment Complete","2011-03-01","1134151756","","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"]
["Frank O McGehee, IV, MD","1134151756","27-0950535","TX","","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","Premila Johnson, MD, LP","Omni PPO","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-29","06/29/2020 - IMS is PAR, therefore this payer is also effective  - Stacey Hudak"]
["Premila L. S. Johnson, MD","1184727562","90-0858471","TX","","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","","Superior","Participating","Enrollment Complete","2017-01-01","1184727562","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","","Aetna","Participating","Enrollment Complete","2024-02-01","","","2024-05-20","5/20/2024 Spoke to irish B call ref# 6192826533 616 N Main St location eff as of 2/1/2024. FC"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","","Wellmed","Participating","Confirm Par Status","2021-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2021. PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Application Resubmitted","2023-05-01","9326179","","2024-09-27"," Unable to get confirmation from Brandy or Hannah if the requested termination would be stopped. I submitted application via delegated roster on 9/27/2024. FC"]
["Johnny L Flitton, PA","1437356730","84-2617748","TX","Midland Medicine PA","Humana","Participating","Payor Follow Up","2024-04-01","","","2024-07-18","Per Humana rep Jona P (1-800-448-6262, ref# 2000392187965), provider is par and linked to TIN, eff 04/01/2024. Location confirmation pending. PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1437356730","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 01/11/2024 all locations. PIN is NPI."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-29","1437356730","","2024-07-05","Per michelle.killough@pswca.org, 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"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","1437356730","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","1437356730","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 12/20/2023 for all locations. NPI# is PIN."]
["Johnny L Flitton, PA","1437356730","84-2617748","TX","Midland Medicine PA","BCBSTX","Participating","Enrollment Complete","2024-08-20","","","2024-08-19","Received email confirmation, provider is PAR and linked to TIN/location, eff. 8/20/2024. Participating LOBs:  BAV - Blue Advantage HMO, BCA - BlueChoice PPO, HME - Health Select, HMO - Blue Essentials, MCH - Medicare Advantage HMO, PMC - Medicare Advantage PPO, SNP - Dual Eligible Special Needs Plan, WEL - WellMed MA HMO. PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","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","","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","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","WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2021-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2021. PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","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","WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2021-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2021. PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2020-04-03","","","2024-12-26","Received email confirmation enrollment complete, eff. 4/03/2020. PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","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","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","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","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","84-2617748","TX","Midland Medicine PA","Triwest VA","Participating","Enrollment Complete","2024-10-01","","","2024-09-18","Received email confirmation, \"Provider is in TriWest VA CCN network activation process.  Target effective date 10/1/24 in BCBSTX system.\" PA."]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-08-01","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-09-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-29","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Johnny L Flitton, PA","1437356730","84-2617748","TX","Midland Medicine PA","Broadspire Services Inc.","In Process","Pending Contracting","2023-12-18","","","2024-04-30","Pending group contract, in process. See group record for status updates. Jen Videan"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 10/4/2024. AS"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","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","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-10","","","2024-07-01","this location has been linked to the group record and provider is listed under the group. Nothing further is needed. MS"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","12235261","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Allen E Gibson, MD","1912068446","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-08-23","1912068446","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 8-23-2016 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Allen E Gibson, MD","1912068446","47-5554737","TX","Midland Inpatient Medical Association","PPHP","Participating","Enrollment Complete","2020-04-15","","","2024-10-04","Received email confirmation Sept roster is processed. Provider is participating, linked to TIN and location, effective 4/15/2020. PA."]
["Allen E Gibson, MD","1912068446","47-5554737","TX","","Humana","Participating","Re-Credentialing","2020-01-01","1912068446","","2024-02-19","2/19/2024 - submitted recred status via delegated monthly roster on 02/15/2024. PA."]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","Premier Family Care, Inc","Liberty Mutual","Participating","Enrollment Complete","2009-10-23","1760501720","752656723","2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","Aetna","Participating","Enrollment Complete","2020-12-01","","","2025-08-11","08.05.2025 MG: Called Aetna @ 1-800-353-1232 to obtain PNP/FU status for the provider and spoke to Moana. Per rep, NPI# is on file for the provider and is participating effective 12/30/2020 under the group and TIN#. Physical location is on file. Provider ID is 9631791. Call ref# 256049998."]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","Premier Family Care, Inc","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","","Tricare Prime","Participating","Enrollment Complete","2014-11-04","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","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","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"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","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"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2023-08-21","1760501720","","2025-08-22","Approval ltr rcvd. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Enrollment Complete","","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","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","","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","","Alliance WC","Participating","Enrollment Complete","2024-02-23","1376723361","","2024-11-14","Per Michelle Killough at michelle.killough@pswca.org location has been added to group profile. 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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","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","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","","Humana","Participating","Enrollment Complete","2020-03-20","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 03/20/2020. PA."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","","Cigna","Facility Enrollment","Enrollment Complete","2023-09-20","8867748","","2023-10-16","Received confirmation. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2017-11-30","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024 location has been added, eff. 11/30/2017 . PA"]
["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","","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 1/01/2022. PA."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","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","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","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"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30","1376723361","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal.  - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","13780299","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","13780299","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","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"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","Premier Family Care, Inc","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","","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","","Aetna","Participating","Enrollment Complete","2024-02-01","","","2024-05-20","5/20/2024- Spoke to Audrey call ref #6192822735 616 N Main participating as of 2/1/2024. FC"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-26","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","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","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","","Sedgwick","Participating","Enrollment Complete","2024-05-29","1376723361","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 2/21/2024 for all locations. NPI# is PIN."]
["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","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","","Amerigroup","Participating","Enrollment Complete","2023-09-08","","","2025-05-29","Received confirmation via roster from Mindy Wiggins, provider participating as of 3/3/2025 with Medicare products. FC"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","","USA PPO","Participating","Enrollment Complete","2018-02-04","","","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 2/4/2018.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-10-01","","","2025-08-13","08/05/2025 AB: Called Cigna @ 800-882-4462 to obtain PNP/FU status for the provider and spoke to Aby S. Per rep, Provider is INN and link to GRP and TIN, eff 10/1/2023. PIN 8867748. Physical Location is on file. Call Ref#AbyS08052025."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","","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","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-09-01","","","2025-06-19","Received confirmat from Jenny call ref#20484676 via phone call, provider participating eff date 9/1/2024. FC"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","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","","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","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","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","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","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","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","","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-17","Received email confirmation from PPHP, provider is linked to the location/TIN, eff. 7/11/2024. PA."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Confirm Par Status","2022-05-01","","","2025-02-20","Received confirmation from Cynthia F. provider is par, linked to TIN/location, eff. 5/1/2022. PA."]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2016-07-25","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","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","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","1376723361","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 3/1/2018 for all locations. PIN is the NPI."]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-01-03","","","","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","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","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","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-29","","","2024-07-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","1376723361","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 2/21/2024 for all locations. NPI# is PIN."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1376723361","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1376723361","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1376723361","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023 for all location. PIN is NPI."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Humana","Participating","Enrollment Complete","2020-03-20","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 03/20/2020. PA."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Medicare","Participating","Enrollment Complete","2024-07-01","","","2024-06-28","Group enrollment has been approved and this location has been linked and is active effective 7/1/2024. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2025-08-13","08/05/2025 AB: Called Cigna @ 800-882-4462 to obtain PNP/FU status for the provider and spoke to Aby S. Per rep, Provider is INN and link to GRP and TIN. PIN 8867748. Physical Location is on file. Call Ref#AbyS08052025."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 1/01/2022. PA."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-29","1376723361","","2025-09-09","09/09/2025 AC: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI. Loc not on file."]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","1376723361","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Sapna Chilka, MD","1790972610","20-8658501","TX","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","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","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-08-14","","","2025-08-28","CAQH profile/ COI updated next attestation due 12/26/25 SG"]
["Ajay K Vaikuntam, MD","1447415476","47-5554737","TX","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","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2017-07-10","P01909454","","2020-03-25","3/25/2020--Per online check, provider is now PAR effective 07/10/2017 with provider number P01909454. Attached welcome letter to payor line\ntisha rader"]
["Ajay K Vaikuntam, MD","1447415476","47-5554737","TX","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","Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2019-12-01","1225182314","","2020-08-03","8/3/2020 - Emailed Tracy Diapolo and confirmed this provider is NOT with PriMed. That agreement has dissoled with UHC and the phone rep was incorrect in sharing this information. However, she confirmed the provider has been credentialed directly with UHC and all else is well. - Stacey Hudak"]
["Tareq Hulali, MD","1194813709","90-0956632","TX","Tareq Hulali, MD LLLP","United Health Care","Participating","Enrollment Complete","2024-11-05","","","2025-02-12","Received product roster from UHC confirming reinstatement and forwarded to provider. Product roster includes effective dates for product lines. PA."]
["Tareq Hulali, MD","1194813709","90-0956632","TX","Tareq Hulali, MD LLLP","Omni PPO","Participating","Enrollment Complete","2019-01-21","1194813709","","2020-06-25",""]
["Shailesh Jain, MD","1215922802","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2023-12-04","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 12/04/2023. PA."]
["Shailesh Jain, MD","1215922802","75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2023-12-04","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 12/4/2023. FC"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","Premier Family Care, Inc","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"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2023-12-04","","","2024-05-24","Par through Multiplan enrollment, eff. 12/04/2023. PA"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-12-04","","","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 TIN & location 2402 W Wall. PA."]
["Staton Awtrey, MD","1376556019","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2011-08-01","1101456","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2011 PID # 1101456-tisha rader"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","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 9/1/2021.  DCannon"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2012-12-31","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 12/31/2012.  DCannon"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-03-20","TXB138584","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","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","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"]
["Juan C Gil, MD","1558392779","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2013-09-28","1558392779","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Juan C Gil, MD","1558392779","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: Verification request has been emailed to TXMAContracting@CignaHealthcare.com to verify provider credentialing status."]
["Rebecca A Sanchez, PA","1174846364","46-3131679","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"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","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","Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-11-18","P02450879","DU5783","2020-08-28","08/28/2020 - moved to completed status after confirming EFF date through payer portal - Stacey Hudak"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","Midland Texas Orthopedic Group Inc","Humana","Participating","Confirm Par Status","2020-04-15","1174846364","","2025-02-11","Received email confirmation provider is par, linked to TIN & location, eff. 04/15/2020. PA"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2020-03-02","1174846364","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","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","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","","United Health Care","Terminated","Terminated","2016-05-19","002904472","","2023-10-25","10/25/2023 Per email received from Priscilla Albertine at MQA, Dr. Wolbert's UHC contracted terminated effective 8/23/2023.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2010-07-14","1881711778","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Amerigroup","Participating","Add Info Submitted","2020-04-15","01618929","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","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","West Texas Allergy, PA","Superior","Participating","Enrollment Complete","2017-01-01","1881711778","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Cigna","Participating","Enrollment Complete","2010-08-01","9097673","","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"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-18","For Locations: 5000 Briarwood Ave/5424 19th St/ 07/17/2025 MQ: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","Caprock (CapStar)","Participating","Add Info Submitted","2012-03-01","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","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","","HealthSmart PPO","Participating","Add Info Submitted","2011-02-01","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2017-09-14","1881711778","","2020-08-19","8/19/2020 - Rec'd confirmation that this provider is affiliated with the PRIMED DELEGATED ROSTER 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"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","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."]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","","Amerigroup","Participating","Enrollment Complete","2020-07-02","1124350442","","2020-07-15","07/15/2020 - Rec'd welcome letter stating this provider is EFF 7-2-2020 with STAR, STAR+PLUS & Star Kids products - Stacey Hudak"]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","Ayodele O Olowookere MD, PA","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2012-03-01","1487837712","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1487837712","","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"]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Re-Credentialing","2006-06-01","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Aaron B Stike, MD","1366652315","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-08-12","08.06.2025 KF: Called First Health Coventry @ 800-226-5116 and spoke with Crystal. Provider is in network and link to TIN effective 10/01/2024. Location is on file. PIN is 2322619. Call ref# 1670982"]
["Aaron B Stike, MD","1366652315","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-09-04","","","2024-10-02","Provider is linked to location. MS"]
["Aaron B Stike, MD","1366652315","75-2656723","TX","Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2024-09-01","","","2024-09-12","Received email confirmation provider is PAR, and linked to TIN/location, eff. 9/1/2024. Provider is participating in the following LOB's:  CHIP RSA, Star Health Foster Care, Chip, Star, Star Plus, Star Kids, MMP Medicaid, Chip Perinate, Exchange, Medicare, MMP Medicare, and MAPD. PA."]
["Viktor Miro, MD","1073856019","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2024-11-04","6100963","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 11/4/2024. FC"]
["Viktor Miro, MD","1073856019","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2024-11-04","","","2025-02-05","Received confirmation via email from German Aviles, provider participating as of 11/4/2024. FC"]
["Viktor Miro, MD","1073856019","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2023-12-08","","","2025-09-18","Medicaid Revalidation has been approved on 09/18/25. Effective date of 11/23/2025 thru 11/22/2030. VA Request # 20761352"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","Wellcare","Participating","Enrollment Complete","2024-09-01","P10005064100","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","Delight Pediatrics","Omni PPO","Participating","Enrollment Complete","2024-05-22","","","2024-08-27","As per Kodi Cox provider participating as of 5/22/2024 received via email. FC"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","Omni PPO","Participating","Enrollment Complete","2024-05-22","","","2024-08-27","As per Kodi Cox provider participating as of 5/22/2024 received via email. FC"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","Delight Pediatrics","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-08-20","08/20/2025 MQ:Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing  status."]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","Delight Pediatrics","Tricare Prime","Enrollment Stopped","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","Boon Chapman","Participating","Thru Other Payor","2024-05-22","","","2024-12-10","Boon-Chapman serves as a third-party administrator for Aetna and is accessible via the Aetna network. PA."]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","Delight Pediatrics","BCBSTX","Participating","Enrollment Complete","2024-09-04","","","2025-08-12","Received email confirmation provider is PAR and linked to TIN/location, eff. 8/1/2025. Provider is participating in the following LOB's: Blue Advantage HMO : 8/1/2025 \nBCBS PPO: 8/1/2025. FC"]
["Michael T Caglia, MD","1568789550","85-3162122","TX","Basin Dermatology","TriWest HC Alliance","Pending Other Enrollment","Payor Follow Up","","","","2025-07-18","07/17/2025 MQ: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Michael T Caglia, MD","1568789550","85-3162122","TX","Basin Dermatology","Multiplan","Participating","Enrollment Complete","2017-03-13","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 3/13/2017.  DCannon"]
["Joan S R Petalcorin, MD","1619008141","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Joan S R Petalcorin, MD","1619008141","75-2656723","TX","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"]
["Alim M Ladha, MD","1093935975","45-3020135","TX","Alim M. Ladha, MD","Galaxy Health","Participating","Enrollment Complete","2014-11-04","1093935975","","2020-07-16","7/16/2020 - Rec'd email from the payer that contains a spreadsheet showing the providers effective date - Stacey Hudak"]
["Alim M Ladha, MD","1093935975","45-3020135","TX","Alim M. Ladha, MD","United Health Care","Participating","Enrollment Complete","2017-09-09","3517020","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Melissa Ann Hicks, PA","1184905895","46-3131679","TX","Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","In Process","Application Submitted","","","","2025-08-27","Roster has been submitted to updates@primehealthservices.com Atten Alexis Mountry.  VA"]
["Melissa Ann Hicks, PA","1184905895","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicaid","In Process","Application Submitted","","","","2025-10-06","Medicaid Application submitted for Premier.  Request # 20799066 VA"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2022-02-15","","","2022-05-05","5/5/2022 Rcvd email from Scott & White confirming that the February delegation roster has been completed and the provider are now loaded and PAR w/ group TIN/locations effective 2/15/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2022-02-15","","","2022-05-05","5/5/2022 Rcvd email from Scott & White confirming that the February delegation roster has been completed and the provider are now loaded and PAR w/ group TIN/locations effective 2/15/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","TriWest HC Alliance","Participating","Enrollment Complete","2022-01-10","","","2022-02-08","2/8/2022 Per email from Jamie Roberts @ Aetna provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1235484114","","2024-03-28","Per TMHP Dr. PIllarisetty is active at 4911 Andrews Hwy effective 03/28/2024 and active at 421 N Tom Green effective 03/05/2024. Jen Videan"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","Amerigroup","Participating","Application Resubmitted","2022-01-10","12802966","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","Ambetter","Participating","Enrollment Complete","2025-10-01","","","2025-10-06","Per the October SHP Validation report, provider is enrolled, linked to TIN/location, eff. 10/1/2025. ML"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-07-18","For locations: 421 N Tom Green Ave/4911 Andrews Hwy/ 07/17/2025 MQ: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","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"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","","Rail Road Medicare","Participating","Enrollment Complete","2016-09-16","P01752760","DW7662","2024-08-20","Provider is enrolled and linked to this group. MS"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","","Amerigroup","Participating","Enrollment Complete","2024-09-09","","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 9/9/2024. AS"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-12-09","","","2024-08-23","Provider is linked to this location. MS"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","","Galaxy Health","Participating","Enrollment Complete","2024-09-09","","","2025-02-03","Received  confirmation via email from Karen Avalos, provider participating as of 9/9/2024. FC"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","","Superior","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, effective 10/1/2024, linked to TIN & location, effective 10/1/2024."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-25","Per UHC rep Jeevanantham via online chat: \"The requested provider is having an active contract under the respective TIN with an effective date of 10/07/2024.\" PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-25","Per UHC rep Jeevanantham via online chat: \"The requested provider is having an active contract under the respective TIN with an effective date of 10/07/2024.\" PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-06-07","","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 9/1/2024 for all locations. PIN is the NPI."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-06-01","6S4368","423838","2024-06-17","Received welcome letter. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-07-24","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 07/24/2024. PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-08-16","","","2024-09-19","Please see status updates under Alliance WC payor line. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-08-16","","","2024-09-19","Please see status updates under Alliance WC payor line. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-06-01","1073686","","2024-06-10","This is a facility contract, so midlevels will bill services under the group instead of individual. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-06-01","1073686","","2024-06-10","This is a facility contract, so midlevels will bill services under the group instead of individual. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2025-05-19","Received confirmation via email from Aimeleen Diamse from First Health, provider particiapating as of 8/1/2024. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Enrollment Stopped","Application Submitted","","","","2024-07-17","Submitted via delegated roster on 7/15/2024. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-01","Q00774595","DX4335","2024-07-01","Provider has been approved. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","1285175927","","2025-09-16","09/16/2025 AC: Per email response received from SPNEAST@sedgwickcms.com on 09/04/2025, provider NPI# is on file for the provider and is credentialed effective 9/18/2024 for all locations. NPI# is PIN."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","Tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 AC: For location: 616 N Main St/ 4705 Briarwood Ave/ 6301 Andrews Hwy/ 6950 Eastridge Rd./ 3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 AC: For location: 616 N Main St/ 4705 Briarwood Ave/ 6301 Andrews Hwy/ 6950 Eastridge Rd./ 3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-08-16","1285175927","","2024-09-19","Rcvd approval ltr. Effective 08/16/2024. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2025-02-06","Received confirmation via phone call from Jerome call ref#1407655, provider participating as of 8/1/2024. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2025-02-06","Received confirmation via phone call from Jerome call ref#1407655, provider participating as of 8/1/2024. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email confirmation provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-07-01","","","2024-10-31","Received confirmation via delegated roster provider participating as of 7/1/2024. FC"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-08-06","","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-06-12","1285175927","","2024-06-12","Per updates@primehealthservices.com,  Effective 06/12/2024, Henry Sirengo is now enrolled with Tax ID: 47-3465832. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-06-10","","","2024-11-26","Provider is linked to all 5 locations. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-06-10","","","2024-11-26","Provider is linked to all 5 locations. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-06-10","","","2024-11-26","Provider is linked to all 5 locations. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-10","Panel is closed to new enrollments. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. \nLocation is linked to provider per payor website. PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-13","","","2024-09-12","Received email confirmation from BCBSTX, provider is par, eff. 6/13/2024, and linked to TIN/locations. Provider is participating in the following LOB's: •       Blue Choice PPO: 06/21/2024\n•       Blue Advantage HMO: 06/21/2024 \n•       Blue Essentials HMO: 06/21/2024 \n•       Health Select: 06/21/2024 \n•       Medicare Advantage PPO: 06/21/2024 \n•       TriWest T5 TriCare Program: 01/01/2025 . PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-13","","","2024-09-12","Received email confirmation from BCBSTX, provider is par, eff. 6/13/2024, and linked to TIN/locations. Provider is participating in the following LOB's: •       Blue Choice PPO: 06/21/2024\n•       Blue Advantage HMO: 06/21/2024 \n•       Blue Essentials HMO: 06/21/2024 \n•       Health Select: 06/21/2024 \n•       Medicare Advantage PPO: 06/21/2024 \n•       TriWest T5 TriCare Program: 01/01/2025 . PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-10-07","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  10/07/2024.  PA."]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-10-07","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  10/07/2024.  PA."]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1053601344","","2020-06-10","06/10/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-03-03","1053601344","","2020-09-24","Delegated Entity Name: UT PHYSICIANS (PREV. UCP)\n\n*Primed Delegation termed with UHC on 1/1/2020"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","","Omni PPO","Participating","Application Resubmitted","2019-05-21","1053601344","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","","","2020-09-09","Confirmed provider is participating with PPO, H&W and GEN networks (GEN is behavioral health) (list of networks attached). Kimberly Frazier"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-29","1972816189","","2020-08-19","08/19/2020 - Rec'd response 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"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","Permian Cardiology Inc.","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","","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","","Multiplan","Participating","Enrollment Complete","2018-01-30","1972816189","","2020-02-12","02/12/2020 - rec'd confirmation from the payer stating \" Provider:Evbu Enakpene \nNetwork: MPI\nNetwork Participation effective:1/30/2018\nContract Source Group contract through DELEGATED PARTY: West Texas Physicians Alliance\" - Stacey Hudak"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","","381744701","356723201","2024-01-01","Per TMHP, provider is enrolled and license has been updated. Jen Videan"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","Midland Medicine PA","CAQH","Participating","CAQH Reattested","2025-08-07","","","2025-08-07","08/07/2025 CAQH Reattested-updated Cred Cont-dvineyard"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","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","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-08-01","1760860720","","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"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-10-27","","","2023-11-05","Provider linked eff 10/27/23. MS"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-11-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-01-01","1760860720","","2020-08-31","08/31/2020 - moved to completed status after reviewing the follow up completed note - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","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","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-11-01","","","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 11/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","Midland Medicine PA","Wellmed","Panel Closed","Panel Closed","2022-01-01","","","2025-06-05","Received email from WellMed stating that enrollment was denied due to no current network need for additional providers of this specialty in the area. Reconsideration is allowed after 12 months from the date of notification. They will keep the provider’s information on file and may reach out in the future if a need is identified. Fowarded notification to provider. PA."]
["Amber J White, PA","1255614970","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-03-01","1255614970","","2020-09-09","09/09/2020 - moved to completed status after reviewing last note - Stacey Hudak"]
["Amber J White, PA","1255614970","47-5554737","TX","","Medicaid","Participating","Enrollment Complete","2016-08-02","1255614970","364596201","2024-09-19","Request number: 20550664 is closed-approved. License has been updated. Jen Videan"]
["Amber J White, PA","1255614970","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-10-01","1255614970","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the PriMed delegation - Stacey Hudak"]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-12-20","6703681","","2020-06-25","6-25-2020 - Moved to completed status based on info rec'd during follow up complete call - Stacey Hudak"]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-10-01","1447412895","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the primed delegation - Stacey Hudak"]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-10-18","P01762092"," DW7662","2020-05-04","050/4/2020 - verified and moved to EFF status - Stacey Hudak"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","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","Permian Digestive Disease Center PA","Cigna","Participating","Enrollment Complete","2024-01-01","8628903","","2024-01-16","Received confirmation update eff 1/1/2024.  W202401103687976  MS"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","Permian Digestive Disease Center PA","BCBSTX","Participating","Add Info Submitted","2016-02-12","","","2025-04-03","Submitted letter of intent to Connie Traylor requesting addition to Blue Cross Medicare Advantage HMO LOB. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","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","Permian Digestive Disease Center PA","Caprock (CapStar)","Participating","Application Resubmitted","2024-01-01","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Triwest VA","In House Enrollment","In House Enrollment","","","","2024-01-10",""]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Multiplan","Participating","Enrollment Complete","2024-01-01","","","2024-06-20","Spoke to Bri W. (call ref# 10514349) 3409 Andrews Hwy location participating as of 1/1/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","Permian Digestive Disease Center PA","Omni PPO","Participating","Enrollment Complete","2020-09-01","1447406137","","2020-09-04","09/04/2020 - IMS is effective, therefore this payer line is also effective - Stacey Hudak"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","Permian Digestive Disease Center PA","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Aetna","Participating","Application Resubmitted","2019-09-01","1447406137","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","Permian Digestive Disease Center PA","Aetna","Participating","Enrollment Complete","2024-01-01","","","2024-05-20","5/20/2024- Spoke to Dan R. call ref #6192810917 3409 Andrews Hwy address effective as of 1/1/2024, provider listed as a SPEC. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","Permian Digestive Disease Center PA","Amerigroup","Participating","Application Resubmitted","2018-05-03","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","United Health Care","Participating","Enrollment Complete","2019-09-01","","","2020-11-10","11/10/20 - Rcvd confirmation email Ref # PR5483501 that provider has been linked and loaded effective 9/1/2019.  MPIN # 002945847"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-05","","","2024-11-12","Received confirmation via email from Lee Kinard with HealthSmart. Provider participating as of 2/5/2024. AS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-05","","","2024-11-12","Received confirmation via email from Lee Kinard with HealthSmart. Provider participating as of 2/5/2024. AS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-02-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 2/05/2024.  PA"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","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","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-01","","","2025-08-28","8/27/2025 AC: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com,  Provider NPI# is on file and is participating under TIN and GROUP effective 3/1/2024 for all locations. PIN is the NPI."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","1972506442","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["John Petersen, MD","1972506442","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-02-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD","1972506442","47-3465832","tx","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","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-07-01","","","2025-08-13","For locations: 6950 Eastridge Rd./ 6301 Andrews Hwy/ 616 N Main St./ 4705 Briarwood Ave 08/05/2025 KC: Called 800-882-4462 and spoke w/ Jaq A at Cigna. Stated provider is innetwork and link to the tax id effective 07/01/2024.Provider id# 0208158.Physical location is onfile.Call ref# Jaq A 08/05/2025."]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","Participating","Payor Follow Up","","","","2024-07-29","Receivied email confirmation provider is linked to locations. Awaiting effective date confirmation. PA."]
["John Petersen, MD","1972506442","47-3465832","TX","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","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","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-02-05","","","2024-04-05","3/21/2024 - received email confirmation from Karen Avalos (kavalos@ghn-mci.com) Feb. roster completed. Provider is now PAR, eff. 02/05/2024. PA."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-02-05","","","2024-04-05","3/21/2024 - received email confirmation from Karen Avalos (kavalos@ghn-mci.com) Feb. roster completed. Provider is now PAR, eff. 02/05/2024. PA."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2024-03-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2024-03-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2025-01-30","","","2025-01-30","1/30/2025 Invalid UN/PW-dvineyard"]
["John Petersen, MD","1972506442","47-3465832","TX","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","WesTex Urgent Care, PLLC","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1972506442","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St/ 6301 Andrews Hwy/ Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1972506442","","2025-09-09","09/09/2025 AC: For locations: 4705 Briarwood Ave/ 6950 Eastridge Rd./ 616 N Main St./ 5514 N Big Spring St/ 6301 Andrews Hwy/ Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. PIN is NPI."]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-21","1972506442","","2025-09-02","09/02/2025 AC: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com Provider NPI# is on file and is participating under TIN and GROUP effective 7/20/2020 for all locations. PIN is the NPI."]
["John Petersen, MD","1972506442","47-3465832","TX","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","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 10/4/2024\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 10/4/2024. AS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 10/4/2024\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 10/4/2024. AS"]
["John Petersen, MD","1972506442","47-3465832","TX","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","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 02/05/2024.  PA"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 02/05/2024.  PA"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-02-05","","","2024-05-17","Received email confirmation from Marina Martinez (marina.martinez@usamco.com) provider is PAR, eff. 02/05/2024. PA."]
["John Petersen, MD","1972506442","47-3465832","TX","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","WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-05","","","2024-05-20","5/20/2024- Spoke to Audrey call ref #6192822735 all locations  participating as of 2/5/2024. FC"]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-03-15","","","2024-07-19","Received roster from HP Delegation; provider is PAR and linked to TIN/locations, eff. 03/15/2024. PA."]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-03-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 3/1/2024. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2024-03-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 3/1/2024. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","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","WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2024-02-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD","1972506442","47-3465832","tx","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","WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","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","Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Add Info Submitted","2019-09-01","1750794749","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","Aetna","Participating","Add Info Submitted","2020-08-01","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","Shylesh Ganta, MD, PA","First Health Coventry","Participating","Add Info Submitted","2020-08-01","3524170","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-08-21","11714128","","2025-08-21","08/21/2025 CAQH Reattested-updated TX DEA exp and uploaded doc-dvineyard"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","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","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-09-15","4216518","","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"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","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","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","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","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","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","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","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","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","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"]
["Ali R Khan, MD","1760714380","47-5554737","TX","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","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","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-09-03","7D0212","423838","2025-02-20","Provider is linked to PTAN 6P6053. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-09-03","7D0212","423838","2024-12-09","Received welcome letter. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-02-12","","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-01-24","1437650934","","2025-08-08","For Locations: 3490 E Yukon Rd./ 616 N Main St./ 6301 Andrews Hwy/ 4705 Briarwood Ave/ 6950 Eastridge Rd. 08.04.2025 JB: Verification request has been emailed to updates@primehealthservices.com, credentialing@primehealthservices.com, providerrelations@primehealthservices.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-02-19","","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 02/19/2025 for all locations. PIN is the NPI"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-02-19","","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 02/19/2025 for all locations. PIN is the NPI"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-10-07","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2025-07-01","","","2025-09-15","Received confirmation via email, provider participating eff date 7/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-10-07","","","2025-02-18","Received email confirmation provider reinstated, linked to TIN & location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-10-24","","","2025-02-20","Provider is enrolled at all locations per the Tricare portal. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-02-06","Received confirmation via telephone call spoke to Daniel call ref#1407169, provider participating as of 10/1/2024. First Health added suite A to 4705 Briarwood location, I will resubmit correction on February roster. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: Verification request has been emailed to TXMAContracting@CignaHealthcare.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-10-07","","","2025-02-11","Received confirmation via email from Emily Starr, provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised to submit  link letter and attach w9 form and send it to intake_pdm@evernorth.com. TAT 20-30 calendar days. Call ref# Aby S 08/05/2025."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised to submit  link letter and attach w9 form and send it to intake_pdm@evernorth.com. TAT 20-30 calendar days. Call ref# Aby S 08/05/2025."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised to submit  link letter and attach w9 form and send it to intake_pdm@evernorth.com. TAT 20-30 calendar days. Call ref# Aby S 08/05/2025."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised to submit  link letter and attach w9 form and send it to intake_pdm@evernorth.com. TAT 20-30 calendar days. Call ref# Aby S 08/05/2025."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised to submit  link letter and attach w9 form and send it to intake_pdm@evernorth.com. TAT 20-30 calendar days. Call ref# Aby S 08/05/2025."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised to submit  link letter and attach w9 form and send it to intake_pdm@evernorth.com. TAT 20-30 calendar days. Call ref# Aby S 08/05/2025."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised to submit  link letter and attach w9 form and send it to intake_pdm@evernorth.com. TAT 20-30 calendar days. Call ref# Aby S 08/05/2025."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised to submit  link letter and attach w9 form and send it to intake_pdm@evernorth.com. TAT 20-30 calendar days. Call ref# Aby S 08/05/2025."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised to submit  link letter and attach w9 form and send it to intake_pdm@evernorth.com. TAT 20-30 calendar days. Call ref# Aby S 08/05/2025."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-08-11","For Locations:4705 Briarwood Ave/6950 Eastridge Rd./6301 Andrews Hwy/616 N Main St./3490 E Yukon Rd./08.05.2025 JB: Called Cigna @ 800-882-4462 to obtain PNP/FU status of the provider and spoke with Aby. Per rep, provider is OON. Rep advised to submit  link letter and attach w9 form and send it to intake_pdm@evernorth.com. TAT 20-30 calendar days. Call ref# Aby S 08/05/2025."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 11/01/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 11/01/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 11/01/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 11/01/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 11/01/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 11/01/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 11/01/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 11/01/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 11/01/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 11/01/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-11-26","","","2025-02-20","Confirmed enrollment via Tricare Portal. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-11-01","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 11/01/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-09-02","09/02/2025 MQ: Per email response received on 08/21/2025 from Texas_CorCare@corvel.com, Provider NPI# is on file and is participating under TIN and GROUP effective 07/20/2020 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2025-09-19","09/19/2025 MQ: For location: 6950 Eastridge Rd./ 6301 Andrews Hwy/616 N Main St./ 4705 Briarwood Ave/3490 E Yukon Rd./ Verification request has been emailed to TXMAContracting@cignahealthcare.com to verify provider credentialing status."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2025-09-08","09/08/2025 MQ: Per email response received on 08/23/2025 from updates@primehealthservices.com, Provider NPI# is on file and is participating under TIN and GROUP effective 05/23/2023. Loc is on file. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2024-05-06","","","2025-02-05","Received confirmation via email from Caprock, provider participating as of 5/6/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2025-09-15","09/15/2025 MQ: Per email response received on 09/04/2025 from SPNEAST@sedgwickcms.com, Provider NPI# is on file and is participating under TIN and GROUP effective 02/19/2025 for all locations. PIN is the NPI"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2025-02-01","","","2025-06-19","Received confirmation from Sheila D call ref#2045807, provider is participatng eff date 2/1/2025. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-07-01","Received roster from Lanetrice M. Provider is listed linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-10-07","6763058","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2025-01-14","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2024 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-01-24","1437650934","","2025-02-03","Per Michelle Killough at michelle.killough@pswca.org location has been added to group profile. 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"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-10-07","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-05-29","Received confirmattion via email from First Health (#1539095), provider participating as of 10/1/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-05-29","Received confirmattion via email from First Health (#1539095), provider participating as of 10/1/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-05-29","Received confirmattion via email from First Health (#1539095), provider participating as of 10/1/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-05-29","Received confirmattion via email from First Health (#1539095), provider participating as of 10/1/2024. FC"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2024 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2024 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2024 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2024 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2024 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2024 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2024 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2024 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2024 for all locations. PIN is the NPI."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2025-08-28","08/27/25 MQ: Per email response received on 08/21/2025 from wwtxcontracts@texasmutual.com, Provider NPI# is on file and is participating under TIN and GROUP effective 12/1/2024 for all locations. PIN is the NPI."]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","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","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","Premier Family Care, Inc","IMS","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","IMS","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","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","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","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","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","Premier Family Care, Inc","HealthSmart PPO","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","HealthSmart PPO","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-10-09","Taxonomy code 207R00000X has been disenrolled. 207RC0200X enrolled, effective 03/22/2024. Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-10-09","Taxonomy code 207R00000X has been disenrolled. 207RC0200X enrolled, effective 03/22/2024. Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","CAQH","Participating","CAQH Reattested","2025-09-03","","","2025-09-03","09/03/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","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","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","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","Premier Family Care, Inc","First Health Coventry","Participating","Re-Credentialing","2023-05-01","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","First Health Coventry","Participating","Re-Credentialing","2023-05-01","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","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","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","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","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","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","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","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","Premier Family Care, Inc","Multiplan","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Multiplan","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","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","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","Premier Family Care, Inc","Caprock (CapStar)","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Caprock (CapStar)","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","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","Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Amerigroup","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-01","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","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","Premier Family Care, Inc","TriWest HC Alliance","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","","TriWest HC Alliance","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","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","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","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","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-01","","","2025-08-12","08.05.2025 JJ: Called Aetna @ 1-800-353-1232 to obtain FU status of the provider and s/w Kyle. Per rep, provider is in-network and linked to TIN but eff date depends to each active location. PIN: 6655255. Rep advised that there are 2 locations on file but same address with different eff date: 11/01/2022 and 05/15/2025. Call ref#: 256060620."]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Aetna","Participating","Enrollment Complete","2022-11-01","","","2025-08-12","08.05.2025 JJ: Called Aetna @ 1-800-353-1232 to obtain FU status of the provider and s/w Kyle. Per rep, provider is in-network and linked to TIN but eff date depends to each active location. PIN: 6655255. Rep advised that there are 2 locations on file but same address with different eff date: 11/01/2022 and 05/15/2025. Call ref#: 256060620."]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","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","Premier Family Care, Inc","Omni PPO","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","Omni PPO","Participating","Re-Credentialing","2022-04-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","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"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","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","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","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","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","47-5554737","TX","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","47-5554737","TX","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","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","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","West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD","1265872592","86-3825791","TX","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","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","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","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","West Texas Ob/Gyn","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-07-18","For Locations: 400 Rosalind Redfern Grover Pkwy/ 421 N Tom Green Ave/ 4911 Andrews Hwy 07/17/2025 MQ: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-07-18","For Locations: 400 Rosalind Redfern Grover Pkwy/ 421 N Tom Green Ave/ 4911 Andrews Hwy 07/17/2025 MQ: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-07-18","For Locations: 400 Rosalind Redfern Grover Pkwy/ 421 N Tom Green Ave/ 4911 Andrews Hwy 07/17/2025 MQ: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-07-18","For Locations: 400 Rosalind Redfern Grover Pkwy/ 421 N Tom Green Ave/ 4911 Andrews Hwy 07/17/2025 MQ: Verification request has been emailed to gfitzpatrick@TriWest.com and providercontracting@triwest.com to verify provider credentialing status."]
["Deepika Devalla, MD","1265872592","47-5554737","TX","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","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-09-15","13885700","","2025-09-15","09/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD","1265872592","86-3825791","TX","West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD","1265872592","47-5554737","TX","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","47-5554737","TX","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","86-3825791","TX","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","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","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","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","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","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","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","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","47-5554737","TX","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","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","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","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","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","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","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","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","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","47-5554737","TX","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","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","47-5554737","TX","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","86-3825791","TX","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","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","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","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","47-5554737","TX","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","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","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","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-08-07","","","2025-08-07","08/07/2025 CAQH Reattested-updated Cred Cont-dvineyard"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","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","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","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","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","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","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","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","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","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","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","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","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2021-03-01","367256001","364596201","2025-06-25","Per TMHP, license has been updated. Request is closed/approved. Provider is showing active. Jen Videan"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","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","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","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","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","Midland Inpatient Medical Association","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","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","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","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","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","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","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","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","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","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","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","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","","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","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Application Resubmitted","2017-06-06","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","HealthSmart PPO","Participating","Application Resubmitted","2017-06-06","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","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","","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","Midland Inpatient Medical Association","First Health Coventry","Participating","Application Resubmitted","2022-12-15","3546231","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","First Health Coventry","Participating","Application Resubmitted","2022-12-15","3546231","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","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","","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","Midland Inpatient Medical Association","Multiplan","Participating","Application Resubmitted","2020-04-03","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Multiplan","Participating","Application Resubmitted","2020-04-03","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","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","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","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","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","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-08-01","","","2024-07-22","As per January roster provider participating as of 8.1.2020 listed as a SPEC. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","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","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","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2017-05-17","372790101","364596201","2024-05-08","Rcvd approval ltr. Jen Videan"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","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","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","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","","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","Midland Inpatient Medical Association","IMS","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","IMS","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","TriWest HC Alliance","In Process","Payor Follow Up","","","","2025-10-02","Emailed TRICAREProviderInquiries@TriWest.com for status. Jen Videan"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","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"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","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"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Application Resubmitted","2018-04-20","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Amerigroup","Participating","Application Resubmitted","2018-04-20","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Application Resubmitted","2020-03-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2020-03-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","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","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","","Omni PPO","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","IMS complete"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C","1013456649","47-5554737","TX","","Omni PPO","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","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","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","","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","Premier Family Care, Inc","Multiplan","Participating","Application Resubmitted","2019-04-05","1396930426","West Texas Physicians Alliance","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Multiplan","Participating","Application Resubmitted","2019-04-05","1396930426","West Texas Physicians Alliance","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","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","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","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","","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","Premier Family Care, Inc","Caprock (CapStar)","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","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","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","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-26",""]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-26",""]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Omni PPO","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","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","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","","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","Premier Family Care, Inc","IMS","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","IMS","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","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","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","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","","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","Premier Family Care, Inc","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","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","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","","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","Premier Family Care, Inc","Amerigroup","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","","Amerigroup","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","Premier Family Care, Inc","TriWest HC Alliance","Participating","Payor Follow Up","","","","2025-10-07","10/07/2025 MQ: Verification request has been emailed to HumanaProviderSupport@TriWest.com to verify provider credentialing status."]
["Tzu-Ching Wu, MD","1396930426","75-2656723","TX","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","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","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","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","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","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","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":7,"n_cols":11,"rows_kept":7,"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"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","Rail Road Medicare","Pending Other Enrollment","Pending Medicare",null,null,null,"2025-02-25","Pending Medicare approval. MS"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Provider Load","Provider Load",null,null,null,"2025-02-25"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","Medicaid","In Process","Pending Info/Document",null,null,null,"2025-03-13","Per Raymond's intake form his primary taxonomy code is 207RC0200X. Medicaid does not recognize this taxonomy code for NPs. It is used for MD or DOs only. Emailed MQA to advise what taxonomy code should be used as primary for Raymond's Medicaid enrollment. Jen Videan"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2025-04-07","7J6402",519061,"2025-03-13","Recevied welcome letter. MS"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-02-27",null,null,"2025-02-27","2/27/2025 CAQH Reattested-updated TX AP lic and uploaded doc and re-uploaded COI MP107275 doc-dvineyard"]
["Raymond A Barlow, II, APRN-NP","PE - Midland Inpatient Medical Association","Cigna","In Process","Application Submitted",null,null,null,"2025-02-28","Application submitted via email to Medical Onboarding. MS"]