{"text_format":"1","workbook":"xlsx","n_sheets":4,"sheets":["Form","Database","TaxIDSearch","NPISearch"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":3,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Form","index":0,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":false,"merged":[]}

{"sheet":"Database","index":1,"n_rows":21423,"n_cols":19,"rows_kept":4500,"cut":true,"hidden":true,"merged":[],"bounds":{"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0}}
["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","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","2025-06-09","11483093","","2025-06-09","06/09/2025 CAQH Reattested-all information is correct and up to date-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","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","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","CAQH","Participating","CAQH Reattested","2025-05-08","14218808","","2025-05-08","05/08/2025 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","","","2024-02-15","Per phone call, the provider is linked to TIN eff 11/6/2023. MS"]
["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","Enrollment Complete","2023-11-01","","","2023-12-19","Rcvd TMHP Welcome letter. Provider effective 11/01/2023. Jen Videan"]
["Anusha Ammu, MD","1386135713","75-6000608","TX","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","75-2656723","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","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","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","","","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","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["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","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-01-06","Per updates@primehealthservices.com, provider has been added. Effective 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","2025-05-06","","","2025-05-06","05/06/2025 CAQH Reattested-added symplr email again bc it was removed-dvineyard"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-02-12","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. 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","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","","","","2024-07-09","Per providerdata@careworks.com request to add 3490 E Yukon Rd. has been completed. Jen Videan"]
["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","","","2024-06-25","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"]
["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","","","2024-10-14","Per Dee Dee Johnson at Texas Mutual site visit completed on 07/26/2024. Jen Videan"]
["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","","","","2025-02-09","Per providerdata@careworks.com, address has been added. Jen Videan"]
["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","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","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","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","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","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","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2024-02-13","Provider effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","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","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","","","2024-03-05"," Per spneast@sedgwickcms.com address has been added to provider's profile effective 05/17/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-28","","","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","","","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","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","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","","","2024-08-06","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["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","","","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","","","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","","","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","","","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","","","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","","","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","","","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","In Process","Application Resubmitted","","","","2025-04-21","Application resubmitted and AO Signature Page uploaded. App was sent to the provider for signature. T042120250003580 MS"]
["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","","","2025-01-14","Please see status updates under group record payor line. Jen Videan"]
["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","","","","2024-05-31","Facility Enrollment. Providers services are billed through the facility, not an individual claim. MS"]
["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","","","","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","Pending Contracting","","","","2024-11-26","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-18","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","No Value Specified","2025-05-06","","","","05/06/2025 CAQH Reattested-added symplr email again bc it was removed.-dvineyard"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","No Value Specified","2025-05-06","","","","05/06/2025 CAQH Reattested-added symplr email again bc it was removed.-dvineyard"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","No Value Specified","2025-05-06","","","","05/06/2025 CAQH Reattested-added symplr email again bc it was removed.-dvineyard"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","No Value Specified","2025-05-06","","","","05/06/2025 CAQH Reattested-added symplr email again bc it was removed.-dvineyard"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","No Value Specified","2025-05-06","","","","05/06/2025 CAQH Reattested-added symplr email again bc it was removed.-dvineyard"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","No Value Specified","2025-05-06","","","","05/06/2025 CAQH Reattested-added symplr email again bc it was removed.-dvineyard"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","No Value Specified","2025-05-06","","","","05/06/2025 CAQH Reattested-added symplr email again bc it was removed.-dvineyard"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","No Value Specified","2025-05-06","","","","05/06/2025 CAQH Reattested-added symplr email again bc it was removed.-dvineyard"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","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","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD","1841780806","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","","","","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.","In Process","Application Submitted","2023-04-14","","","2025-04-28","Name change request from last name Wood to Lucas emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["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","Texas Municipal League","Participating","Enrollment Complete","2023-05-19","","","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","In Process","Payor Follow Up","2024-06-19","1225283963","","2025-05-19","Per providerdata@careworks.com, your request has been moved on for processing. Please allow 7-10 business days for completion of your request. 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","","","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","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","In Process","Action Needed","2023-07-01","","","2025-04-24","Please notify the payer of the providers last name change. MS"]
["Bethany M Lucas, PA","1225283963","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","","","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","2025-06-09","","","2025-06-09","06/09/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["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","","","2025-05-08","Per wwtxcontracts@texasmutual.com,  I’ve got this updated in our system. It will take a couple weeks to reflect in the directory, but it’s all set to be changed there as well. Jen Videan"]
["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","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","Application Submitted","","","","2025-04-04","Payer requested roster completion. This was completed for the group and emailed back to TXMA Contracting. MS"]
["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.","Pending Other Enrollment","Pending Contracting","","","","2025-04-08","Emailed Priscilla for status of signed agreement. Jen Videan"]
["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","","","","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","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. 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","2025-05-05","","","2025-05-05","05/05/2025 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","","","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","","","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.","In Process","Application Submitted","","","","2025-04-08","Signed contract and roster emailed to Bre Waynes at Corvel. Jen Videan"]
["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","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission. Pending UHC enrollment. PA."]
["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","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission. PA."]
["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","Pending Other Enrollment","Pending Medicare","","","","2025-03-26","Pending Medicare approval. MS"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Ambetter","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","HealthSmart PPO","In Process","Application Submitted","","","","2025-05-15","Application submitted via delegated roster. FC"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Humana","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Superior","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission. Pending Superior enrollment. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Medicaid","In Process","Application Submitted","","","","2025-05-30","Application submitted via TMHP. Request ID: 20718664. Your application has been submitted and is now under review. Your request number is: 20718664. Jen Videan"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Wellcare","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission.  Pending Superior enrollment. 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","In Process","Payor Follow Up","","","","2025-04-18","Received email from payer the application is being processed. Ref 13987890. MS"]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Galaxy Health","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","Scott&White (First Care)","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission. 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","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission. PA."]
["Sulay P Patel, MD","1265798763","27-4061759","TX","Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2025-05-28","","","2025-05-28","05/28/2025 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.","Caprock (CapStar)","In Process","Application Submitted","","","","2025-05-15","Application submitted via delegated roster. 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","2025-05-28","","","2025-05-28","05/28/2025 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.","Pending Other Enrollment","Pending Contracting","","","","2025-04-08","Emailed Priscilla for status of signed agreement. Jen Videan"]
["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","","","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","","","","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","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","Application Submitted","","","","2025-04-04","Payer requested roster completion. This was completed for the group and emailed back to TXMA Contracting. MS"]
["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.","In Process","Application Submitted","","","","2025-04-08","Signed contract and roster emailed to Bre Waynes at Corvel. Jen Videan"]
["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","","","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","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["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","2025-05-28","","","2025-05-28","05/28/2025 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","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","2025-05-28","","","2025-05-28","05/28/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Vamsi K Korrapati, MD","1407149883","47-5554737","TX","Midland Inpatient Medical Association","Triwest 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","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"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2025-04-01","","","2025-05-09","Per April SHP Validation report, provider is listed par, linked to TIN/location, eff. 4/1/25. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Superior","Participating","Enrollment Complete","2025-04-01","","","2025-05-09","Per April SHP Validation report, provider is listed par, linked to TIN/location, eff. 4/1/25. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","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 Kiani, MD","1043692411","47-5554737","TX","","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 Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2025-03-18","","","2025-05-01","Approval ltr rcvd. Effective 03/18/2025. Jen Videan"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Medicaid","Participating","Enrollment Complete","2025-03-18","","","2025-05-01","Approval ltr rcvd. Effective 03/18/2025. Jen Videan"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2025-03-03","","","2025-05-09","Received product roster from UHC. Provider is listed PAR, linked to TIN/location, eff. 3/03/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Wellmed","Participating","Enrollment Complete","2025-03-03","","","2025-05-09","Received product roster from UHC. Provider is listed PAR, linked to TIN/location, eff. 3/03/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2025-03-03","","","2025-04-22","Received via email from Emily Starr provider participating eff 3/3/2025. FC"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","HealthSmart PPO","Participating","Enrollment Complete","2025-03-03","","","2025-04-22","Received via email from Emily Starr provider participating eff 3/3/2025. FC"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2025-03-03","6848379","","2025-04-15","Receved confirmation via email from Mary Hanna, provider participating as of 3/3/2025. FC"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Aetna","Participating","Enrollment Complete","2025-03-03","6848379","","2025-04-15","Receved confirmation via email from Mary Hanna, provider participating as of 3/3/2025. FC"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Tricare Prime","In Process","Panel Closed","","","","2025-03-04","Location is not tricare credentialed and threfore panel is closed. MS"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Tricare Prime","In Process","Panel Closed","","","","2025-03-04","Location is not tricare credentialed and threfore panel is closed. MS"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2025-04-01","","","2025-04-14","Provider listed PAR per SHP April validation report, eff. 04/01/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Ambetter","Participating","Enrollment Complete","2025-04-01","","","2025-04-14","Provider listed PAR per SHP April validation report, eff. 04/01/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Cigna","In Process","Payor Receipt Validated","","","","2025-03-07","Received confirmation of receipt. Ref 13957220. MS"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Cigna","In Process","Payor Receipt Validated","","","","2025-03-07","Received confirmation of receipt. Ref 13957220. MS"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","In Process","Pending Medicare","","","","2025-02-28",""]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Rail Road Medicare","In Process","Pending Medicare","","","","2025-02-28",""]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","CAQH","In Process","CAQH Reattested","2025-04-16","","","2025-04-16","04/16/2025 CAQH Reattested-updated TX Lic/BC exp and uploaded doc-dvineyard"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","CAQH","In Process","CAQH Reattested","2025-04-16","","","2025-04-16","04/16/2025 CAQH Reattested-updated TX Lic/BC exp and uploaded doc-dvineyard"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2025-03-03","","","2025-05-29","Received confirmation via roster from Mindy Wiggins, provider participating as of 3/3/2025. FC"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Amerigroup","Participating","Enrollment Complete","2025-03-03","","","2025-05-29","Received confirmation via roster from Mindy Wiggins, provider participating as of 3/3/2025. FC"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","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 Kiani, MD","1043692411","47-5554737","TX","","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 Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","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 Kiani, MD","1043692411","47-5554737","TX","","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 Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2025-03-18","","","2025-03-12","Received welcome letter. PTAN 7J6349"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Medicare","Participating","Enrollment Complete","2025-03-18","","","2025-03-12","Received welcome letter. PTAN 7J6349"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2025-03-01","","","2025-05-19","Received confirmation via email from Aimeleen Diamse from First Health, provider particiapating as of 3/1/2025. FC"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","First Health Coventry","Participating","Enrollment Complete","2025-03-01","","","2025-05-19","Received confirmation via email from Aimeleen Diamse from First Health, provider particiapating as of 3/1/2025. FC"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","In Process","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","TriCare Standard","In Process","Enrollment Stopped","","","","2025-03-06","location is now in the TriWest territory. Enrollment will need to go through TriWest. MS"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2025-03-03","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 3/3/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Humana","Participating","Enrollment Complete","2025-03-03","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 3/3/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2025-04-01","","","2025-04-14","Provider listed PAR per SHP April validation report, eff. 04/01/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","Wellcare","Participating","Enrollment Complete","2025-04-01","","","2025-04-14","Provider listed PAR per SHP April validation report, eff. 04/01/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2025-03-03","","","2025-05-09","Received product roster from UHC. Provider is listed PAR, linked to TIN/location, eff. 3/03/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","United Health Care","Participating","Enrollment Complete","2025-03-03","","","2025-05-09","Received product roster from UHC. Provider is listed PAR, linked to TIN/location, eff. 3/03/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","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 Kiani, MD","1043692411","47-5554737","TX","","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 Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","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/location, eff 3/3/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","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/location, eff 3/3/2025. PA."]
["Sarah Kiani, MD","1043692411","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2025-03-02","","","2025-05-01","Received confirmation via email from Addella Yarnold, provider participating as of 3/3/2025. FC"]
["Sarah Kiani, MD","1043692411","47-5554737","TX","","IMS","Participating","Enrollment Complete","2025-03-02","","","2025-05-01","Received confirmation via email from Addella Yarnold, provider participating as of 3/3/2025. FC"]
["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","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."]
["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","","","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","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["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","","","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","","","2020-09-04","Provider is participating under group Tax ID and correct location. Kimberly Frazier"]
["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","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","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","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. 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","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","","","","2025-04-07","Recredentialing approval ltr rcvd. Jen Videan"]
["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","2025-06-05","","","2025-06-05","06/05/2025 CAQH Reattested-updated TX DEA exp and uploaded doc-dvineyard"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","","","","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","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","","","2025-01-24","Welcome ltr rcvd. Effective 12/31/2024. Jen Videan"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","","","2020-08-05","8/5/2020- Per email response received from  Texas Mutual on  8/4/2020, provider NPI# is on file for the provider and is participating effective 5/1/2019 under the group and TIN#. Physical location is on file. - Elonah Grace B. Gelig"]
["Kristin L Rettig, PA","1164778767","46-3131679","TX","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","","","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","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["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","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. 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","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","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","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","Amerigroup","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-09-15","","","2023-08-18","8/18/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, 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","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","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","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","United Health Care","Participating","Enrollment Complete","2023-07-19","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, 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","Omni PPO","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, 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","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-06","Location added under group record, but is not a Tricare Credentialed location. MS"]
["Rachel K Longacre, 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","Humana","Participating","Enrollment Complete","2020-01-01","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 01/01/2020. PA."]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Rachel K Longacre, 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","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Rachel K Longacre, 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","2023-07-19","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-07-19","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, 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","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Ste. 240. MS"]
["Rachel K Longacre, APRN-FNP-BC","1639524861","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, 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","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","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","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","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Rachel K Longacre, 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","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","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","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","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","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","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","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","Boon Chapman","Participating","Enrollment Complete","2023-07-19","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, 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.","In Process","Application Submitted","","","","2025-04-08","Signed contract and roster emailed to Bre Waynes at Corvel. Jen Videan"]
["William Gage Liesman, MD","1144665233","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","In Process","Application Submitted","","","","2025-04-04","Payer requested roster completion. This was completed for the group and emailed back to TXMA Contracting. MS"]
["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.","Pending Other Enrollment","Pending Contracting","","","","2025-04-08","Emailed Priscilla for status of signed agreement. Jen Videan"]
["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","","","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","Application Submitted","","","","2025-03-07","TSCA and required documents emailed to SPNEAST@sedgwickcms.com. Jen Videan"]
["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","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","","","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","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. 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","","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["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","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","2025-05-28","13876531","","2025-05-28","05/28/2025 CAQH Reattested-updated TX Lic exp and uploaded doc-dvineyard"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-28","13876531","","2025-05-28","05/28/2025 CAQH Reattested-updated TX Lic exp and uploaded doc-dvineyard"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-28","13876531","","2025-05-28","05/28/2025 CAQH Reattested-updated TX Lic exp and uploaded doc-dvineyard"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-28","13876531","","2025-05-28","05/28/2025 CAQH Reattested-updated TX Lic exp 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","","","2023-08-01","8/1/2023 Rcvd email confirmation that provider is PAR and linked to group/location effective 6/5/2023.  PID # 7585417.  DCannon"]
["Madhavi Gadiraju, MD","1932541406","75-2656723","TX","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","","","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","","","","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","","","","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","","","","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","","","","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","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","","","","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","2025-05-23","14530139","","2025-05-23","05/23/2025 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","","","","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","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","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","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","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","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","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","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","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-06-06","","","2025-03-19","Per TMHP, request id 20635953 is closed and approved. License has been updated and provider is active. Jen Videan"]
["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","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","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","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","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","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","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","Application Submitted","","","","2025-04-07","Fax sent to 859-455-8650 with the list of all locations to get confirmation from Aetna. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2025-04-07","Fax sent to 859-455-8650 with the list of all locations to get confirmation from Aetna. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2025-04-07","Fax sent to 859-455-8650 with the list of all locations to get confirmation from Aetna. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2025-04-07","Fax sent to 859-455-8650 with the list of all locations to get confirmation from Aetna. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2025-04-07","Fax sent to 859-455-8650 with the list of all locations to get confirmation from Aetna. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2025-04-07","Fax sent to 859-455-8650 with the list of all locations to get confirmation from Aetna. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2025-04-07","Fax sent to 859-455-8650 with the list of all locations to get confirmation from Aetna. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2025-04-07","Fax sent to 859-455-8650 with the list of all locations to get confirmation from Aetna. 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","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","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","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-01-06","Per the payor directory, the provider is active and linked to locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-01-06","Per the payor directory, the provider is active and linked to locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-01-06","Per the payor directory, the provider is active and linked to locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-01-06","Per the payor directory, the provider is active and linked to locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-01-06","Per the payor directory, the provider is active and linked to locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-01-06","Per the payor directory, the provider is active and linked to locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-01-06","Per the payor directory, the provider is active and linked to locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-01-06","Per the payor directory, the provider is active and linked to locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-01-06","Per the payor directory, the provider is active and linked to locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-01-06","Per the payor directory, the provider is active and linked to locations. MS"]
["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","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","","","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","","","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","","","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","","","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","","","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","","","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","","","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","","","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","","","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","","","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","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","","","","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","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","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","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["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","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","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-06-06","","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-03-05","Provider is active and linked to 4214 Andrews Hwy., Ste. 109 & 400 Rosalind Redfern Grover, Ste. 271 per the provider directory. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-03-05","Provider is active and linked to 4214 Andrews Hwy., Ste. 109 & 400 Rosalind Redfern Grover, Ste. 271 per the provider directory. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-03-05","Provider is active and linked to 4214 Andrews Hwy., Ste. 109 & 400 Rosalind Redfern Grover, Ste. 271 per the provider directory. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-03-05","Provider is active and linked to 4214 Andrews Hwy., Ste. 109 & 400 Rosalind Redfern Grover, Ste. 271 per the provider directory. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-03-05","Provider is active and linked to 4214 Andrews Hwy., Ste. 109 & 400 Rosalind Redfern Grover, Ste. 271 per the provider directory. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-03-05","Provider is active and linked to 4214 Andrews Hwy., Ste. 109 & 400 Rosalind Redfern Grover, Ste. 271 per the provider directory. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-03-05","Provider is active and linked to 4214 Andrews Hwy., Ste. 109 & 400 Rosalind Redfern Grover, Ste. 271 per the provider directory. MS"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2025-03-05","Provider is active and linked to 4214 Andrews Hwy., Ste. 109 & 400 Rosalind Redfern Grover, Ste. 271 per the provider directory. MS"]
["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","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","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","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","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","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","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","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","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","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC","1922658319","75-2656723","TX","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","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","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","","","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","","","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","","","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","","","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","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","Tricare Prime","Participating","Enrollment Complete","2020-12-24","","","2021-05-09","5/9/2021 Upon review of the self-service portal, provider is participating under group Tax ID and practice location effective 12/24/2020. KFrazier"]
["Ana M Rodriguez, APRN-FNP-BC","1437790284","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-04-01","","","2021-03-24","3/19/21 (kstrickland) Called Atena SW Daniel Call Ref# 6008130068. He stated provider is in network but couldn't get me a provider ID bc they are waiting for the demographics team to load the date. It will take 30 days. But then you can call back to get a provider id.  DCannon"]
["James D Richardson, MD","1306827266","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Add Info Submitted","2020-01-28","","","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."]
["James D Richardson, MD","1306827266","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."]
["James D Richardson, MD","1306827266","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/6/2023. and linked to location  400 Rosalind Redfern Grover PKWY, suite 230. PA."]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2022-12-19","","","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 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP","1265081616","27-4061759","TX","Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-02-01","","","2023-03-23","3/23/2023 Rcvd email Superior w/ confirmation from that provider is PAR and linked to group effective 2/1/2023.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC","1447882915","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2020-02-11","1B4358","320497","2020-04-23","04/23/2020 - Found porivder as EFF under gorup enrollment through PECOS - Stacey Hudak"]
["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","Texas Municipal League","Participating","Enrollment Complete","","","","2024-09-10","Please see status updates under Alliance WC payor line. Jen Videan"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1922008234","","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"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1922008234","","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"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2014-12-01","1922008234","","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"]
["Cindy Marriner, FNP","1922008234","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."]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2025-02-28","","","2025-05-12","Received email confirmation from Karen Avalos provider is participating, linked to TIN/location, eff.  2/28/2025. PA."]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1922008234","","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"]
["Cindy Marriner, FNP","1922008234","75-2656723","TX","Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","6186781","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 6186781  DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 3/20/2020.   DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2018-04-01","1750796009","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["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","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-29","1750796009","","2020-04-16","04/16/2020 - Rec'd email spreadsheet confirmation from the payer stating this provider is linked to PRI MED DELEGATED agreement with all products under this TIN/Service location - Stacey Hudak\n\n**Verified the provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["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","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 3/20/2020.   DCannon"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2017-08-21","595054YM2M","00304W","2020-02-07","02/07/2020 - note on Payer List provided by the doctor states \"We credential our own Medicare.\" - Stacey Hudak"]
["Swetha Reddy Jangangari, MD","1750796009","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2018-08-01","1750796009","","2020-11-02","11/2/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["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","Boon Chapman","Participating","Enrollment Complete","2018-04-23","1750796009","","2020-10-05","enrolled thru PHCS"]
["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"]
["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","Rail Road Medicare","Participating","Enrollment Complete","2016-12-01","P02500701","DC8592","2020-08-28","08/28/2020 - this provider has been moved to EFF status after confirming through payer portal - Stacey Hudak"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-09-01","1447701602","","2020-10-05","Enrolled thru PHCS"]
["Trinidad R Marquez, APRN-NP","1447701602","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"]
["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","Aetna","Participating","Enrollment Complete","2021-06-01","5152938","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 5152938  DCannon"]
["Trinidad R Marquez, APRN-NP","1447701602","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"]
["Trinidad R Marquez, APRN-NP","1447701602","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2017-02-10","","","2020-09-14",""]
["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","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"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2015-08-30","1154767234","","2020-09-14",""]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","Midland Community Healthcare Services","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"]
["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","Boon Chapman","Participating","Enrollment Complete","2016-07-26","","","2021-09-16","9/15/2021 Received roster from Multiplan listing provider as PAR under group TIN/location effective 7/26/2016.  DCannon"]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-10-07","1154767234","","2020-10-30","10/30/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Oct 7, 2020 12:05:19 PM. Your request was assigned reference number PR-5533533 .\" - Stacey Hudak"]
["Chabacana Maxwell, FNP","1154767234","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2020-03-20","","","2022-04-09","4/09/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 3/20/2020.  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","TriCare Standard","Participating","Enrollment Complete","2020-08-25","1891931341","","2020-09-09","09/09/2020 - moved to completed status after reviewing the last note - Stacey Hudak"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-07-31","7/31/2021 This will be processed by group. KFrazier"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2019-01-01","758005","00304W","2020-08-21","08/21/2020 - Added this payer line to store effective information. This enrollment is not maintained by Symplr - per the clinic, this will be maintained IN HOUSE - Stacey Hudak"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2020-08-01","","","2022-04-13","4/13/2022 Per roster from IMS/Omni provider is PAR and linked to group TIN/location effective 8/1/2020.  DCannon"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2019-09-01","5244447","","2020-05-13","05/13/2020 - rec'd email from the payer stating \"This is to confirm that your request has been completed.\" - Stacey Hudak"]
["Tonya Murphy, FNP","1891931341","83-0358685","TX","Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","","Provider did not select inclusion with this payor; provider specialty pediatrics; not eligible for TriWest VA enrollment"]
["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","Molina","Participating","Enrollment Complete","2019-05-07","","","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 5/7/2019.  DCannon"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1184265050","","",""]
["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","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 3/20/2020.   DCannon"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","888038","00304W","2020-09-21","09/21/2020 - Rec'd proof from the clinic that this service location has been added to the group - Stacey Hudak"]
["Jose Saucedo, APRN-FNP-BC","1184265050","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"]
["Jose Saucedo, APRN-FNP-BC","1184265050","83-0358685","TX","Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-03-01","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 3/1/2022.  DCannon"]
["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","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Jose Saucedo, 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","TX","Midland Medicine PA","Medicare","Participating","Enrollment Complete","2022-06-01","","","2022-06-08","6/8/2022 Per PECOS location has been added to group PTAN # and provider is now linked to location effective 6/1/2022, PTAN # IN5324.  DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","TX","Midland Medicine PA","Cigna","Participating","Enrollment Complete","2022-06-01","3332103","","2022-05-26","5/26/2022 Rcvd email from Cigna that providers new location has been added and linked to group TIN effective 6/1/2022.  PID # 3332103.  DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","TX","Midland Medicine PA","United Health Care","Participating","Enrollment Complete","2022-06-01","007772537","","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 6/1/2022.   MPIN# 007772537.   DCannon"]
["Justin D Shanks, APRN-FNP-BC","1205477874","84-2617748","TX","Midland Medicine PA","USA PPO","Participating","Enrollment Complete","2022-06-01","","","2022-07-21","7/21/2022 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 6/1/2022.  DCannon"]
["Hagos Z Aymut, MD","1922548890","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2023-07-01","","","2023-08-11","08.11.2023 S/W April of First Health @ 800-226-5116. Per rep, provider is showing par and link under the Group and TIN with an Effective date 07/01/2023. Provider ID 3709511. Service location is on file. Call ref#:725002.-Danico Gabriel Melendres"]
["Hagos Z Aymut, MD","1922548890","47-5554737","TX","Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Suresh K Ravuri, MD","1750539268","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-06-23","","","2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 6/23/2020.  DCannon"]
["Suresh K Ravuri, MD","1750539268","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2019-09-01","3176267","","2020-05-19","05/19/2020 - Rec'd email from the payer stating \"This is to confirm that your request has been completed\" _ Stacey Hudak"]
["Suresh K Ravuri, MD","1750539268","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2020-06-01","P02503378","DW7662","2020-08-28","08/28/2020 - moved to completed status after finding completed info through payer portal - Stacey Hudak"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-02-12","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["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","Sedgwick","Participating","Enrollment Complete","","","","2025-02-09","Per providerdata@careworks.com, address has been added. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","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. 9/1/2024\n616 N Main st eff. 10/4/2024. AS"]
["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","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-17","Received email confirmation from PPHP, provider is linked to the location/TIN, eff. 7/01/2024. PA."]
["Haley D Brennan, PA-C","1528430865","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"]
["Haley D Brennan, PA-C","1528430865","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"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-10-19","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 10/19/2017.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-08","Welcome ltr rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","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"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-14","","","2025-04-14","04/14/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["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","","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","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2020-04-15","","","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","","","","2025-04-07","Recredentialing approval letter rcvd. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2025-04-07","Recredentialing approval letter rcvd. Jen Videan"]
["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","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","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/05/2023. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2019-10-01","6875567","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 12/15/2018.  DCannon"]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","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"]
["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","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","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","","","","2023-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Haley D Brennan, PA-C","1528430865","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"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Haley D Brennan, PA-C","1528430865","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2018-10-01","","","2023-08-23","Provider is linked to group locations. MS"]
["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","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Haley D Brennan, PA-C","1528430865","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Haley D Brennan, PA-C","1528430865","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"]
["Jordan Elizabeth Friday, NP","1215575576","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"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","","Medicare","Participating","Pending Info/Document","","","","2025-03-04","Pending surrogacy in order to track the providers enrollment. MS"]
["Jordan Elizabeth Friday, NP","1215575576","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2025-05-05","14594087","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Satish Nayak, MD","1518053149","57-1157825","TX","Satish Nayak","Superior","Participating","Enrollment Complete","2017-01-01","1518053149","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Satish Nayak, MD","1518053149","57-1157825","TX","Satish Nayak","Omni PPO","Participating","Enrollment Complete","2004-02-16","1518053149","","2020-06-26",""]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","ADA Adult and Children Family Clinic LLC","United Health Care","Participating","Enrollment Complete","2021-04-13","1922328079","","2021-03-30","3/30/2021 Received email from Rep Kelly Johnson at kelly_l_johnson@uhc.com confirming group and provider are now participating effective 4/13/2021. KFrazier"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","ADA Adult and Children Family Clinic LLC","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."]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","ADA Adult and Children Family Clinic LLC","Boon Chapman","Participating","Enrollment Complete","2023-07-15","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","TX","ADA Adult and Children Family Clinic LLC","CAQH","Participating","CAQH Reattested","2025-04-23","12577050","","2025-04-23","04/23/2025 CAQH Reattested-Verified billing information for Priscilla-dvineyard"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","ADA Adult and Children Family Clinic LLC","HealthSmart PPO","Participating","Enrollment Complete","2020-05-15","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/15/2020.  DCannon"]
["Abiodun A Okin-Ayileka, MD","1922328079","84-4724927","ME","ADA Adult and Children Family Clinic LLC","Amerigroup","Participating","Enrollment Complete","2019-09-18","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/18/2019.  DCannon"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2021-02-12","10499208","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 2/12/2021.  DCannon"]
["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"]
["Jonathan C Burkes, MD","1538571609","46-3131679","TX","Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2020-09-01","","","2025-01-16","Received email confirmation on 01/07/2025 confirming provider reinstated with an effective date of  09/01/2020 for Aetna commercial plans and IFP/ Exchange CVS HMO plan. PA."]
["Carlos Molina, DO","1225277833","75-1997880","TX","Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-07-17","04579869","","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"]
["Carlos Molina, DO","1225277833","26-3789190","TX","Permian Physician Services","Gallagher","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","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","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"]
["Carlos Molina, DO","1225277833","75-1997880","TX","Andrews County Hospital District","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Per Coventry portal provider is enrolled. Jen Videan"]
["Carlos Molina, DO","1225277833","26-3789190","TX","Permian Physician Services","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"]
["Carlos Molina, DO","1225277833","26-3789190","TX","Permian Physician Services","Texas Mutual","Participating","Enrollment Complete","2024-04-01","","","2024-04-05","Approval ltr rcvd. Effective 04/01/2024. Jen Videan"]
["Alyssa Tochterman, MD","1972942209","26-3789190","TX","Permian Physician Services","Alliance WC","Participating","Enrollment Complete","","","","2023-10-02","Per Barry Harris at pswca.org provider is effective 09/22/2023. Jen Videan"]
["Alyssa Tochterman, MD","1972942209","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"]
["Alyssa Tochterman, MD","1972942209","26-3789190","TX","Permian Physician Services","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance notes. MS"]
["Alyssa Tochterman, MD","1972942209","75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2016-08-01","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Alyssa Tochterman, MD","1972942209","75-1997880","TX","Andrews County Hospital District","Texas Mutual","Participating","Enrollment Complete","2023-11-01","","","2023-11-20","Rcvd approval ltr. Provider effective 11/01/2023. Jen Videan"]
["Alyssa Tochterman, MD","1972942209","75-1997880","TX","Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1972942209","","2020-08-21",""]
["Margaret Merriam, DO","1083867147","75-1997880","TX","Andrews County Hospital District","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Per Coventry portal provider is enrolled. Jen Videan"]
["Margaret Merriam, DO","1083867147","26-3789190","TX","Permian Physician Services","Texas Mutual","Participating","Enrollment Complete","2024-04-01","","","2024-04-05","Approval ltr rcvd. Effective 04/01/2024. Jen Videan"]
["Margaret Merriam, DO","1083867147","26-3789190","TX","Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2021-04-14","","","2021-05-09","5/9/2021 Upon review of the self-service portal, provider has been loaded under group Tax ID and location effective 4/14/2021. KFrazier"]
["Margaret Merriam, DO","1083867147","26-3789190","TX","Permian Physician Services","Multiplan","Participating","Enrollment Complete","2020-08-05","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 8/5/2020.  DCannon"]
["Margaret Merriam, DO","1083867147","75-1997880","TX","Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","1083867147","","2020-10-01","10/01/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Margaret Merriam, DO","1083867147","75-1997880","TX","Andrews County Hospital District","Medicare","Participating","Enrollment Complete","","RHC GROUP NPI - Part A Only","","2020-07-28","07/28/2020 - THIS SERVICE LOCATION AND GROUP NPI IS FOR AN RHC FACILITY (part A) only. \n\nThere is no provider link/reassignment for this group.\n\nThis provider is active with Medicare, but cannot be reassigned to this TIN/Group NPI. It bills under facility only, not by provider.  Moved to completed status to remove from work list - Stacey Hudak"]
["Margaret Merriam, DO","1083867147","26-3789190","TX","Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2017-06-05","","","2020-09-14",""]
["Jennifer B Hada-Ondriezek, DPM","1669617981","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"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","Andrews County Hospital District","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Check Coventry portal for enrollment status. Provider currently not showing as active. Jen Videan"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","Andrews County Hospital District","Humana","Participating","Enrollment Complete","2015-01-01","","","2021-07-09","7/9/2021 Called Humana at 800-626-2741 spoke w/ Taylor, call reference # 2000191481297 he confirmed that provider is PAR under TIN and location effective 1/1/2015.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","75-1997880","TX","Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2010-01-15","","","2021-04-18","4/18/2021 Rcvd complete roster from Jamie Roberts <robertsj6@aetna.com> at Aetna listing provider as participating at TIN and locations.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM","1669617981","26-3789190","TX","Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","","","","2021-09-15","7/2/2021- S/W Tierra OF TRICARE Standard @ 8004445445, call was transferred to WPS for further assistance, Spoke to Sandra, as per Rep, NPI#is on file for the provider, shows certified Non particpiating under the group and TIN# effective 6/1/2021-11/1/2022 under the physical location. Provider ID is 26-3789190-79714-C006. to become a Par provider need to contact PR liason for assistance, Rep do not have the contact info and TAT for the process. Call ref# Herminia Gilongos"]
["Shannan Clawson, NP","1972073906","75-1997880","TX","Andrews County Hospital District","Superior","Participating","Enrollment Complete","2020-10-01","1972073906","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the primed roster - Stacey Hudak"]
["Shannan Clawson, NP","1972073906","75-1997880","TX","Andrews County Hospital District","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","First Health Coventry","Participating","Enrollment Complete","2023-07-01","","","2023-08-10","Confirmed active via online portal. MS"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2021-03-01","Q00078955","CE1588","2021-06-01","6/1/2021 Immediately assigned RR PTAN Q00078955 which is effective 3/1/2021 under group RR PTAN CE1588. KFrazier"]
["Kristie M Chu, MD","1780078089","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2021-03-01","423389201","079837301","2021-07-22","7/22/2021 Received a copy of the TMHP approval letter from Candace Wynne at Premier.  TPI # 423389201 effective 3/1/2021.  DCannon"]
["Barbara Norris, NP-C","1720353592","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"]
["Barbara Norris, NP-C","1720353592","75-1997880","TX","Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2014-04-29","1720353592","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Barbara Norris, NP-C","1720353592","75-1997880","TX","Andrews County Hospital District","Humana","Participating","Enrollment Complete","2018-07-01","1720353592","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD","1184035313","26-3789190","TX","Permian Physician 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"]
["Stephanie Jean Fitzgerald, MD","1184035313","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"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2020-09-01","","","2020-10-30","10/30/2020 Confirmed via self-service portal provider is participating under group Tax ID and location effective 9/1/2020. However, she is currently in the recredentialing process, which is why it states 'action needed'. KFrazier"]
["Stephanie Jean Fitzgerald, MD","1184035313","75-1997880","TX","Andrews County Hospital District","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","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"]
["Cynthia A Hill, CNS","1225271224","75-1997880","TX","Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2021-02-01","","","2021-03-08","3/8/2021 Rcvd confirmation from Cigna that provider is now participating under TIN and linked to location effective 2/1/2021.  CPID # 8550635.  DCannon"]
["Cynthia A Hill, CNS","1225271224","75-1997880","TX","Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2022-10-04","","","2024-03-06","Re-Cred completed effective 10/4/2022. MS"]
["Cynthia A Hill, CNS","1225271224","75-1997880","TX","Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2021-12-31","9885355","","2022-02-24","2/24/2022 Per follow-up note from 2/17/2022 Provider NPI# is on file for the provider and is participating effective 12/31/21 under the group and TIN# as out of network, per rep the TAX ID has a Facility Contract, even the Provider is out of network she can still build the claim under the TAX ID and it will be process as in network. PIN 9885355.Physical location is on file. Ref# 6075333572. - DCannon"]
["Rahul Dinesh Puri, MD","1306928098","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"]
["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","Cigna","Participating","Enrollment Complete","2016-04-01","1306928098","","2020-07-23","07/23/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","","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","","Molina","Participating","Enrollment Complete","2020-04-17","1306928098","","2020-09-28","09/28/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rahul Dinesh Puri, MD","1306928098","26-3789190","TX","Permian Physician Services","Boon Chapman","Participating","Enrollment Complete","2016-07-07","1306928098","","2020-10-05","Enrolled thru PHCS"]
["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","","Cigna","Participating","Enrollment Complete","2016-04-01","1306928098","","2020-07-23","07/23/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Rahul Dinesh Puri, MD","1306928098","75-1997880","TX","","First Health Coventry","Participating","Enrollment Complete","","","","2023-07-24","Confirmed enrollment via online directory. MS"]
["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","1184626749","75-1997880","TX","Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Paul Slaughter","1184626749","75-1997880","TX","Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2006-11-16","","","2021-01-22","1/22/2021 - Rcvd email from Healthsmart Provider Services that provider is participating at location under TIN effective 11/16/2020.  DCannon"]
["Maria Montero, MD","1508218843","75-2656723","TX","North Big Spring Family Care","United Health Care","Participating","Enrollment Complete","2020-10-29","754025","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 10/29/2020 and assigned provider ID 754025. KFrazier"]
["Maria Montero, MD","1508218843","75-2656723","TX","North Big Spring Family Care","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."]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-08-21","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective  8/21/2020. DCannon"]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","Andrews County Hospital District","Medicare","Participating","Enrollment Complete","2013-12-25","333694YSCJ","290001","2020-07-31","07/31/2020 - was able to log into group enrollment for Quick Care and confirm that this provider is linked to the correct group PTAN/service location - Stacey Hudak"]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","Andrews County Hospital District","Molina","In Process","Payor Follow Up","","","","2023-10-16","10/16/2023 Sent a 2nd request follow-up email to MHTContractRequest@molinahealthcare.com.  Forward original email request submitted back in 2021 to follow-up on request.  DCannon"]
["Christopher Stansell, FNP","1285065946","75-1997880","TX","Andrews County Hospital District","Superior","Participating","Enrollment Complete","2020-10-01","1285065946","","2020-10-01","10/01/2020 - Rec'd email from the payer stating this providers enrollment has been completed with PriMed Delegation - Stacey Hudak"]
["Lindsay M Friesenhahn, PA","1558979013","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-11-01","","","2025-04-16","Approval ltr rcvd. Effective 11/01/2024. Jen Videan"]
["Lindsay M Friesenhahn, PA","1558979013","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-10-22","","","2024-11-27","Provider is linked to this location. MS"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-22","Per TMHP request has been closed and provider is enrolled. 4214 Andrews Hwy STE 107, Midland, TX, 79703-4813 effective 03/15/2023. Jen Videan"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-10-12","","","2021-01-18","1/18/2021 - Rcvd confirmation email from Cigna that provider has loaded and is participating under TIN and location effective 10/12/2020 CPID # 4138818.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2021-11-22","9212791","","2022-05-11","5/11/2022 Per follow-up note from 12/20/2021 provider is PAR and linked to group TIN/location effective 11/22/2021.  PID # 9212791.  DCannon"]
["Leslie Michelle Rowland, FNP","1720111883","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."]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 4/1/2022.  DCannon"]
["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"]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-09-03","","","2025-05-12","Received product roster from UHC; provider is linked to TIN/location, eff. 09/03/2020. PA."]
["Leslie Michelle Rowland, FNP","1720111883","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2024-08-01","3628663","","2025-03-11","Confirmed. MS"]
["Ni Adams, APRN-NP","1194355339","75-2656723","TX","Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2023-01-19","1.19.2023 S/W Ashanti of First Health @ 800-226-5116. Transferred the call and spoke with Stacey. Provider is on file and participating. Link under the group and TIN effective 12/1/2022. Location is on file. Provider ID is 3634130. Next recredentialing date is every 3 years (12/1/2025). No information for the payer#. -Kim Monique Fabian"]
["Ni Adams, APRN-NP","1194355339","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01","4075624-02","0798373-01","2021-01-04","1/4/2021 Received forwarded approval notice from Candace Wynne in which provider has been assigned TPI 4075624-02, effective 10/1/2020. Revalidation due 12/28/2025. KFrazier"]
["Rachel Ann Murphy, RD","1124637160","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"]
["Rachel Ann Murphy, RD","1124637160","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-12-07","6258746","","2021-03-24","3/19/21 (kstrickland) Called Atena SW Hazel call ref # 6008138304. Provider is in network. I had her double check the address and it is correct. Provider ID: 6258746 effective 12/7/2020.  DCannon"]
["Rachel Ann Murphy, RD","1124637160","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-23","","","2025-05-23","05/23/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Eliana Kelley, APRN-FNP-BC","1184278251","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."]
["Eliana Kelley, APRN-FNP-BC","1184278251","75-1997880","TX","Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2022-02-25","","","2024-02-28","Re-Cred has been completed. eff 2/25/2022. MS"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2022-08-18","","","2022-09-15","9/15/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 8/18/2022.  DCannon"]
["Julie Parker, APRN-NP","1720538606","75-1997880","TX","Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2021-01-07","6945139","","2021-04-18","4/18/2021 Rcvd complete roster from Jamie Roberts <robertsj6@aetna.com> at Aetna listing provider as participating at TIN and locations.  DCannon"]
["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","Permian Gastroenterology PA","Medicare","Participating","Enrollment Complete","2023-12-12","00320K","","2024-01-24","Novitas received the providers signatures after the rejection letter was sent out. The client decided to wait to see if Novitas would still go ahead and process the application. Approval letter received eff 12/12/2023. MS"]
["Daniel J Dominguez, APRN-FNP-BC","1720610447","74-2348334","TX","Permian Gastroenterology PA","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","Triwest VA","Participating","Enrollment Complete","2024-05-01","","","2024-05-02","Received email confirmation from Scarlett Abigail, provider is PAR, eff. 05/01/2024. PA."]
["Meagan Leighann Cunningham, APRN-FNP-BC","1891302931","75-1997880","TX","Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2021-03-11","9559559","","2021-03-12","3/12/2021 Received an email from discovercigna@information.cigna.com confirming providier is now participating under group Tax ID and assigned PIN number 9559559, effective 3/11/2021. KFrazier"]
["Meagan Leighann Cunningham, APRN-FNP-BC","1891302931","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"]
["Meagan Leighann Cunningham, APRN-FNP-BC","1891302931","75-1997880","TX","Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2021-10-07","","","2023-06-02","06.02.2023 S/W Trina of First Health @ 800-226-5116. Rep advised to call aetna first to see if provider is credentialed with aetna. S/W Chris of Aetna @ 1-800-353-1232. Per rep, provider is showing participating with First Health and link under the Group and TIN with an Effective date 10/07/2021. Provider ID 6806263, Payer ID 60025 and Recredentialing date 10/07/2024. Service location is on file. Call ref#:6149441125. - Danico Gabriel Melendres"]
["Bola O Jaiyeola, NP","1235605064","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-02-08","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 02/08/2021.  DCannon"]
["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","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","","","2024-12-23","Per updates@primehealthservices.com, provider has been added effective 05/23/2023. Jen Videan"]
["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","In Process","Payor Follow Up","2025-01-01","7F4080","423838","2025-05-01","Received development requesting the AO signature form. This was submitted back via fax. MS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","In Process","Payor Follow Up","2025-01-01","7F4080","423838","2025-05-01","Received development requesting the AO signature form. This was submitted back via fax. 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","","","2025-03-04","Approval ltr rcvd. Effective 03/01/2025. Jen Videan"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-12-20","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Ernest J Buck, MD","1861504987","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-12-20","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","","","2025-04-24","Approval ltr rcvd. Effective 04/16/2025. Jen Videan"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-04-16","","","2025-04-24","Approval ltr rcvd. Effective 04/16/2025. Jen Videan"]
["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","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","Texas Municipal League","Participating","Enrollment Complete","2025-02-14","","","2025-02-24","Please see status updates under Alliance WC payor line. Jen Videan"]
["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","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-02-27","","","2025-02-28","Welcome ltr rcvd. Effective 02/27/2025. Jen Videan"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-02-14","","","2025-02-24","Welcome ltr rcvd. Effective 02/14/2025. Jen Videan"]
["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","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","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-12-20","No enrollment is needed. Provider is loaded and billing out under the group TIN. MS"]
["Ernest J Buck, MD","1861504987","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-23","","","","04/23/2025 CAQH Reattest-all information is correct and up to date-archived IL Prac Loc's per email from Fernanda/Tricia since per provider he is not renewing IL Lic-dvineyard"]
["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","Rail Road Medicare","Participating","Enrollment Complete","2022-12-01","","","2023-05-24",""]
["Amanda Compton, MD","1679953517","26-3789190","TX","Permian Physician Services","United Health Care","Participating","Enrollment Complete","2022-12-01","","","2023-02-28","2/28/2023 Rcvd email from UHC that January delegated roster provider load has been completed and provider is PAR and linked to group TIN effective 12/1/2022.  MPIN# 006893323.  DCannon"]
["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","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","2023-04-06","4/6/2023 Per confirm par status note -  provider is showing participating with an Effective date 12/01/2022 and link under the Group and TIN. Provider ID 3629097, Recredentialing date 12/01/2025. Service location is on file. DCannon"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-11","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","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."]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-07-01","","","2024-10-25","Received confirmation from Brandy Smith via delegated roster provider participating as of 7/1/2024. FC"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","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."]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-20","","","2024-06-18","Received email confirmation provider is now par with BCBSTX, eff. 6/20/2024, participating in the following networks:\n\nBAV - Blue Advantage HMO\t\nBCA - BlueChoice PPO\t\nHME - Health Select\t\nHMO - Blue Essentials\t\nPMC - Medicare Advantage PPO"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2024-06-11","","","2024-06-11","Panel is closed to new enrollments. MS"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","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"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","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, Yukon/N Main/Andrews Hwy/Eastridge eff date 8/1/2024 and Briarwood location eff date 12/4/2024. FC"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-06-11","5155848","","2024-06-11","This is a facility contract, so midlevels will bill services under the group instead of individual. MS"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","tx","WesTex Urgent Care, PLLC","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.  07/01/2024.  PA."]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","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."]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-06-11","","","2024-06-25","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"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-06-11","","","2024-06-25","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"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","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."]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","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"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","","","","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"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","Tx","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-10-02","Per the Tricare portal, she is linked to this location. MS"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-06-17","Provider has been loaded to 5/6 locations. MS"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-07-01","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 07/01/2024. PA."]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Application Resubmitted","","","","2025-03-18","Application resubmitted. FC"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","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."]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","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"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-07","","","2025-05-07","05/07/2025 CAQH Reattested-updated CAQH PW- all information is correct and up to date-dvineyard"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","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."]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-05-10","Q00774406","DX4335","2024-07-01","received confirmation. MS"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","In Process","Enrollment Complete","2024-05-10","6S4338","423838","2024-06-17","Received welcome letter. MS"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","In Process","Enrollment Complete","2024-05-10","6S4338","423838","2024-06-17","Received welcome letter. MS"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","Please see status updates under Alliance WC payor line. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-07-01","","","2025-05-27","Per UHC rep Helen, ref# 05230154, provider is participating under group's TIN, eff. 07/01/2024. PA."]
["Lisa A. Hernandez, APRN-FNP-BC","1942766092","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"]
["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","United Health Care","Participating","Enrollment Complete","2021-05-07","5784146","","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 5/7/2021 and assigned provider ID 5784146. KFrazier"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-03-23","","","2022-06-11","6/11/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 3/23/2022.  DCannon"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2021-05-10","","","2022-06-29","6/29/2022 Per email received from Priscilla Albertine at MQA from a follow-up email she received from USA PPO provider is PAR and in linked to group TIN effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2021-05-10","","","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 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","","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"]
["Orlando Enrique Garner Cruz, MD","1417309105","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2021-05-10","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Kristin M Moose, APRN-FNP-BC","1215213970","75-2182177","TX","Debbie P. Reese, MD PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-12-11","","","2025-02-28","Received email from HPRegion, provider is linked to TIN/location combination, eff. 12/11/2023. PA."]
["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","Amerigroup","Participating","Enrollment Complete","2024-05-23","","","2024-06-19","As per May WellPoint roster, Andrews Hwy location eff as of 5/23/2024. FC"]
["Emily Baker Butler","1053817940","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-04-30","Received confirmation the provider's medicare record has been updated with the correct last name. MS"]
["Emily Baker Butler","1053817940","75-2656723","TX","","Medicare","Participating","Enrollment Complete","","","","2024-04-30","Received confirmation the provider's medicare record has been updated with the correct last name. MS"]
["Emily Baker Butler","1053817940","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-08-09","","","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 8/9/2021.  DCannon"]
["Emily Baker Butler","1053817940","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2021-08-01","1R7343","0008AH","2024-08-14","Approval of correct name update. MS"]
["Emily Baker Butler","1053817940","75-2656723","TX","","HealthSmart 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"]
["Emily Baker Butler","1053817940","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2021-08-01","426462401","","2021-08-30","8/30/2021 Received an email from Candace Wynne the provider's Medicaid has been approved with assigned TPI 426462401 under group effective 8/1/2021. KFrazier"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","6764944","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/1/2021. FC"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2021-10-08","","","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","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 09/01/2021 Jen Videan"]
["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","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["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","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","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","","","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","2021-07-01","","","2023-09-08","Provider is currently enrolled with all locations under WesTex. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2025-04-07","Recredentialing approval letter rcvd. Jen Videan"]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2025-04-07","Recredentialing approval letter rcvd. Jen Videan"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","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"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-04-15","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024 location has been added, eff. 04/15/2020 . PA"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","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"]
["Jeffery Dickson, NP","1851865067","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"]
["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","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["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","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","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","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","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."]
["Jeffery Dickson, NP","1851865067","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-12-06","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 12/06/2021. Jen Videan"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP","1851865067","47-3465832","TX","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"]
["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","Aetna","Participating","Enrollment Complete","2021-09-01","6764944","","2024-05-20","5/202/24 Spoke to Alex call ref#6192816326 616 N Main St  location participating as of 02/1/2024. FC"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2023-01-03","","","2023-03-20","3/20/2023 Rcvd email from Caprock that March delegation roster load has been completed.  Provider is PAR and linked to group TIN/location effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","","Multiplan","Participating","Application Resubmitted","2021-08-13","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","IMS","Participating","Application Resubmitted","2023-01-03","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","Cigna","Participating","Enrollment Complete","2023-01-03","","","2023-08-14","08.14.2023 S/W Tom of Cigna @ 1-800-882-4462, Provider is showing participating and link under the Group and TIN with an Effective date 01/03/2023. Provider ID 9669133. Service address is on file. Call ref#:TomF08142023.-Danico Gabriel Melendres"]
["Sandra Maerzacker, MD","1396190823","92-1786827","TX","Sandra Maerzacker, MD, PLLC","Medicaid","Participating","Enrollment Complete","2024-05-01","1396190823","","2024-06-14","Approval ltr rcvd. Effective 05/01/2024. Jen Videan"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-06-06","","","2023-08-01","8/1/2023 Rcvd email confirmation that provider is PAR and linked to group/location effective 6/6/2023.  PID # 3896115.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-06-06","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/6/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","","Aetna","Participating","Enrollment Complete","2023-06-06","6898581","","2023-08-16","8/16/2023 Per follow-up note - provider NPI# is on file for the provider and is participating effective 06/06/23 under the group and TIN#. Location address is on file. PIN# 6898581. DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted","2023-06-06","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-01","","","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 8/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP","1740807304","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-01","","","2023-03-08","3/8/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 8/1/2022.   DCannon"]
["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","Cigna","Participating","Enrollment Complete","2021-10-21","4000052","","2021-10-28","10/28/2021 Per follow-up notes.  Provider NPI# is on file for the provider and is participating effective 10/21/2021 under the group and TIN#. PIN 4000052. Physical location is on file. Call ref# Roberts10272021."]
["Addis Getahun, MD","1548765183","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Add Info Submitted","2022-04-05","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Addis Getahun, MD","1548765183","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2021-10-21","1V7718","519061","2021-10-25","10/25/2021 Rcvd email from Medicare that provider's app has been approved.  Per PECOS provider's PTAN 1V7718 - Effective 10/21/2021.  DCannon"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3733859","","2023-10-19","10.17.2023 S/W Shanon of First Health @ 800-226-5116 but it was transferred to Trina. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 09/01/2023. Provider ID 3733859. Service location is on file. Call ref#:788591.-Danico Gabriel Melendres"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","","Aetna","Participating","Add Info Submitted","2022-02-01","6103961","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","Midland Inpatient Medical Association","Omni 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","Boon Chapman","Participating","Enrollment Complete","2021-12-22","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 12/22/2021.  DCannon"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","","Multiplan","Participating","Enrollment Complete","2021-12-22","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 12/22/2021.  DCannon"]
["Martha Denise Mourning, NP","1922552959","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2021-10-29","","","2022-04-05","4/5/2022 Rcvd email from Joe Rodriguez at Amerigroup confirming provider is PAR and linked to group TIN/location effective 10/29/2021.  DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","","IMS","Participating","Enrollment Complete","2021-11-18","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 11/18/2021.  DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-06-09","","","2025-06-09","06/09/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","","First Health Coventry","Participating","Enrollment Complete","2021-12-01","3087883","","","5/11/2022 Per First Health website provider is PAR and linked to group TIN/location effective 12/1/2022.  PID # 3087883.  DCannon"]
["Daniel Gellan, MD","1811315880","47-5554737","TX","","Omni PPO","Participating","Add Info Submitted","2021-11-18","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-28","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider is effective 02/21/2024. Jen Videan"]
["Brandon H Rayne, PA","1912482209","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-09-01","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","Permian Physician Services","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO","1942568431","75-1997880","TX","Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete","2024-05-21","1942568431","","2024-05-24","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["Ragini Sastry, DO","1942568431","75-1997880","TX","Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO","1942568431","75-1997880","TX","Andrews County Hospital District","Rail Road Medicare","No Enrollment Required","No Enrollment Required","","","","2022-03-10","3/10/2022 No RR Medicare enrollment since provider is not enrolled in Medicare at this location since it is an RHC.  DCannon"]
["Ragini Sastry, DO","1942568431","26-3789190","TX","Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2022-05-01","3218967","","2023-05-02","5/2/2023 Per confirm par status note - Per rep, provider is showing participating with an effective date 05/01/2022 and link under the Group and TIN. Provider ID 3218967, No Payer ID and No recredentialing date. Service location is on file. Call ref#:610385.-DCannon"]
["Ragini Sastry, DO","1942568431","75-1997880","TX","Andrews County Hospital District","Medicaid","Facility Enrollment","Facility Enrollment","","","","2022-05-02","5/2/2022 This is an RHC facility and does not require provider enrollment. DCannon"]
["Judy J Jia, MD","1588983134","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-03-04","2E5656","0008AH","2022-06-13","6/13/2022 Rcvd Medicare approval letter.  PTAN # 2E5656 - effective 3/4/2022.  DCannon"]
["Judy J Jia, MD","1588983134","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2021-01-01","1588983134","","2022-09-07","9/7/2022 Per TMHP web portal provider is PAR and linked to group effective 1/1/2021.  TPI # 1588983134.  DCannon"]
["Judy J Jia, MD","1588983134","75-2656723","TX","","HealthSmart 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","","First Health Coventry","Participating","Re-Credentialing","2022-07-01","2763424","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["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","Caprock (CapStar)","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","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"]
["Claude B Nguyen, MD","1619130929","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"]
["Claude B Nguyen, MD","1619130929","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11","003645447","","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# 003645447.   DCannon"]
["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","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","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"]
["John H Ownby, MD","1558343988","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"]
["John H Ownby, MD","1558343988","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"]
["John H Ownby, MD","1558343988","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"]
["Elena Krendelshchikova, APRN-NP","1356714406","27-4061759","TX","","Medicaid","Participating","Enrollment Complete","","","","2025-02-06","Per TMHP, taxonomy code 363LF0000X effective 01/09/2024. Jen Videan"]
["Elena Krendelshchikova, APRN-NP","1356714406","27-4061759","TX","Permian Cardiology 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."]
["Megan E Rosa, PA","1720698640","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2024-10-15","","","2025-01-03","Per USA rep Jackie H, provider is participating, linked to TIN & location, eff. 10/15/2024. PA."]
["Megan E Rosa, PA","1720698640","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-11-01","","","2024-11-07","Provider is par, effective 11/01/2024, per the Novemeber 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"]
["Megan E Rosa, PA","1720698640","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-04","Panel is closed to new location enrollments. MS"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-07-01","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-07-01","","","2022-10-30","10/30/2022 Per follow-up note - 10.25.2022 S/W Daria of Amerigroup @ 800-454-3730. Provider is on file and participating. Link under the group and TIN effective 7/1/2022. Location is on file. Provider ID is 14349222. No recredentialing date provided. DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-07-01","2G4596","0008AH","2022-07-28","7/28/2022 Per PECOS provider is PAR and linked to group effective 7/1/2022.  PTAN # 2G4596.  DCannon"]
["Kendra Cooper, APRN-FNP-BC","1780334193","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"]
["Kendra Cooper, APRN-FNP-BC","1780334193","75-2656723","TX","","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","Texas Municipal League","Participating","Enrollment Complete","2022-09-16","","","2022-09-27","9/27/2022 Rcvd PSWCA - Alliance approval letter.  Provider is PAR and linked to group TIN effective 9/16/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","","Amerigroup","Participating","Re-Credentialing","2022-04-14","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2022-03-14","2E8661","320497","2022-06-21","6/21/2022 Rcvd Medicare approval letter.  PTAN # 2E8661 - effective 3/14/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-05-21","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/21/2022.  DCannon"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-03-04","Received confirmation via email from First Health, provider par as of 10/1/2024. FC"]
["Valarie Ramirez Alcala, PA","1790251031","46-3131679","TX","Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","","","","2024-01-26","TIN is delegated. Confirmed enrollment via Coventry Portal. MS"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-06-02","6/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","Superior","Participating","Follow Up Complete","2022-06-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating with CHIP, CHIP RSA, and CHIP Perinate,  linked to TIN and location, effective 12/1/2024. PA."]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2025-06-05","15556542","","2025-06-05","06/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Caroline D Hammond, PA","1720698574","46-3131679","TX","Midland Texas Orthopedic Group Inc","Omni PPO","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","","Caprock (CapStar)","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"]
["Caroline D Hammond, PA","1720698574","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"]
["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","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","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","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","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","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","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","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","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","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","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","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Innocentia Ifunanya Onyemetu, NP","1790457075","83-0358685","TX","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","Enrollment Complete","2022-08-01","","","2022-08-10","8/10/2022 Per roster received from Superior July monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","Superior","Participating","Enrollment Complete","2022-08-01","","","2022-08-10","8/10/2022 Per roster received from Superior July monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Sridhar R Allam, MD","1700061819","88-1668292","TX","","Medicare","Participating","Enrollment Complete","2022-05-01","2F0275","2F0276","2022-07-20","06/28/2022 Provider is PAR in Texas Medicare, and linked to group.  PTAN # 2F0275 - effective 5/1/2022.  DCannon"]
["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","Premier Texas Kidney Care, PLLC","Cigna","Participating","Enrollment Complete","2022-05-01","0461877","","2022-07-15","7/15/2022 Per confirm par status note on 6/3/2022 - S/W Frank at Cigna, who confirmed provider is credentialed in TX through a delegation and is linked to tax ID as of 5/1/2022. Provider ID is 0461877. Ref # is frank 6/3/2022. HSmith"]
["Vishnu S Brahmandam, MD","1548447899","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"]
["Vishnu S Brahmandam, MD","1548447899","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-08-15","9858576","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 8/15/2022.  PID # 9858576.  DCannon"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-08-26","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 8/26/2022.  DCannon"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-08-01","","","2022-08-10","8/10/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Christopher A Stack, MD","1568704971","75-2656723","TX","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","Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2025-04-09","Online demo update was submitted to add this TIN to the providers current enrollment. T13793248  MS"]
["Raghavendra R Sanivarapu, MD","1437513777","75-2656723","TX","","CAQH","Participating","CAQH Reattested","2025-04-25","","","2025-04-25","04/25/2025 CAQH Reattested-updated bc exp and uploaded doc, added COI per Priscilla and uploaded doc-dvineyard"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","Healing Hands Medical Clinic","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3284256","","2023-07-25","7/25/2023 Per email response from First Health provider is PAR and linked to group effective 11/1/2022.   Billing and mailing address on file are correct.  PID # 3284256 DCannon"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","Healing Hands Medical Clinic","Rail Road Medicare","Participating","Enrollment Complete","2023-01-25","P02703383","","2023-08-21","Confirmed enrollment. MS"]
["Joyce O. Alase, MD","1295168318","88-2797281","TX","Healing Hands Medical Clinic","CAQH","Participating","CAQH Reattested","2025-05-28","","","2025-05-28","05/28/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","Permian Physician Services","Travelers WC","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","Permian Physician Services","IMS","Participating","Enrollment Complete","2022-09-26","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/26/2022.   DCannon"]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Richard Glenn Eby, MD","1598260325","75-1997880","TX","Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2022-09-19","","","2022-10-28","10/28/2022 Per Tricare/Humana Military portal provider is PAR and linked to group TIN/location effective 9/19/2022.  DCannon"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","Permian Physician Services","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"]
["Richard Glenn Eby, MD","1598260325","26-3789190","TX","Permian Physician Services","Alliance WC","Participating","Enrollment Complete","2023-06-02","","","2023-06-14","Rep emailed and confirmed participation. MS"]
["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"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2022-11-28","","","2024-04-15","4/15/2024 New location added to delegated roster. FC"]
["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","Scott&White (First Care)","Participating","Enrollment Complete","2023-02-23","","","2023-02-28","2/28/2023 Per email received from Scott & White provider is PAR and linked to group TIN effective 2/23/2023.  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","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-02-01","","","2023-02-09","2/9/2023 Rcvd confirmation email from Superior that January delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 2/1/2023.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","1285983155","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-11-28","","","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 11/28/2022.  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","Amerigroup","Participating","Enrollment Complete","2022-10-31","","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 10/31/2022.  PID# 14835000.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","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","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","Galaxy Health","Participating","Enrollment Complete","2022-10-31","","","2022-12-31","12/31/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for November has been completed.  Provider is PAR and linked to group TIN effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC","1396470357","83-0358685","TX","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","Caprock (CapStar)","Participating","Enrollment Complete","2022-10-31","","","2022-11-21","11/21/2022 Rcvd email from Caprock that November Delegation roster provider load has been completed.  Provider is PAR and linked to group 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","First Health Coventry","Participating","Enrollment Complete","2022-10-31","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 10/31/2022.  DCannon"]
["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"]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","Debbie P. Reese, MD PA","Galaxy Health","Participating","Enrollment Complete","2023-12-11","","","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 12/11/2023.  DCannon"]
["Taylor Allison Arrington, APRN-FNP-BC","1619603255","75-2182177","TX","Debbie P. Reese, MD PA","Amerigroup","Participating","Enrollment Complete","2023-02-06","","","2024-06-19","Andrews Hwy location participating as of 2/6/2023 via May WellPoint roster. FC"]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-02-10","","","2024-04-26","Approval ltr rcvd. Provider effective 02/10/2024. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-04-30","","","2024-09-04","Confirmed via portal, provider is linked and active. MS"]
["Sacha A Stanley, APRN-FNP-BC","1780399857","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2024-02-01","","","2024-09-09","Received confirmation from Aleece Moerbe via email provider participating as of 2/1/2024. FC"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","Hartford","Delegated - Third Party","Delegated - Third Party","","","","2024-01-31","Check Coventry portal for enrollment updates. MS"]
["Stephanie R Powell, PA-C","1538714076","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"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-06","","","2025-05-06","05/06/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-08-25","8/25/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-02-12","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["Stephanie R Powell, PA-C","1538714076","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"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","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","","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-01","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"]
["Stephanie R Powell, PA-C","1538714076","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."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-12-19","Group has Ancillary contract where all midlevel services are billed under the group contract rather than Ind. claims. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","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."]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2025-02-09","Per providerdata@careworks.com, address has been added. Jen Videan"]
["Stephanie R Powell, PA-C","1538714076","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."]
["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","Boon Chapman","Participating","Enrollment Complete","2023-03-31","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 3/31/2023.  DCannon"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","3592528","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Stephanie Powell. Effective 12/05/2023. 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","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"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, so no credentialing is required for midlevels. MS"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","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","Travelers WC","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","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","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-05-15",""]
["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","BCBSTX","Participating","Enrollment Complete","2023-07-28","","","2023-07-31","07/31/2023 - Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO, Medicare Advantage PPO and Health Select, effective 07/28/2023. PA."]
["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","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-14","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/14/2023.  DCannon"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-03-31","6266360","","2023-09-19","09.19.2023 S/W Mark of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 03/31/2023. PIN: 6266360. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163704296. - Willie Ravas"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-09-06","Rcvd approval letter from Karina Garcia. Effective 08/21/2023 for 210 W Longview, 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Stephanie R Powell, PA-C","1538714076","47-3465832","TX","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 VA","Facility Enrollment","In House Enrollment","","","","2023-12-19",""]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1184108664","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Stacey Jo Guse, NP","1184108664","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"]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-08-23","08.23.2023 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 05/01/2023. Provider ID 3674804. Physical location is on file. Call ref#:734006. - Danico Gabriel Melendres"]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-10","","","2024-07-01","Location has been linked to the group record which rolls to the individual providers record as well. There is no further enrollment needed. MS"]
["Stacey Jo Guse, NP","1184108664","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."]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2017-09-01","","","2025-01-14","Please see status updates under group record payor line. Jen Videan"]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-29","","","2024-08-06","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["Stacey Jo Guse, NP","1184108664","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"]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2025-03-10","Received confiramtion via phone call from Krystal F. Call ref#1455725, provider participating as of 8/1/2024. FC"]
["Stacey Jo Guse, NP","1184108664","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-08-01","","","2023-07-31","07/31/2023 - Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO,  Medicare Advantage PPO and Health Select, effective 08/01/2023. PA"]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-08","","","2025-05-08","05/08/2025 CAQH Reattested-updated BC exp and uploaded doc-dvineyard"]
["Stacey Jo Guse, NP","1184108664","47-3465832","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-07","","","2023-09-07","Rcvd welcome letter from Karina Garcia. Provider effective 09/07/2023. Jen Videan"]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-05-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff. 5/01/2023. PA"]
["Stacey Jo Guse, NP","1184108664","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"]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-05-06","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 9/4/2024\n6950 Eastridge Rd, 4705 Briarwood Ave, 616 N Main St. eff. 6/12/2023\n6301 Andrews Hwy 5/6/2024.\nAS"]
["Stacey Jo Guse, NP","1184108664","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."]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-05-01","","","2024-07-29","Received product roster. Provider is linked to TIN & location, eff. 05/01/2023. PA."]
["Stacey Jo Guse, NP","1184108664","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Application Resubmitted","2023-05-01","","","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 except Longview and Greenbriar. FC"]
["Stacey Jo Guse, NP","1184108664","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."]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","Permian Physician Services","Gallagher","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","Permian Physician Services","CAQH","Participating","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-added COI and uploaded doc-dvineyard"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","Permian Physician Services","Liberty Mutual","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Suhail Sami Daye, MD","1639251481","26-3789190","TX","Permian Physician Services","Boon Chapman","Participating","Enrollment Complete","2017-06-12","","","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 6/2/2017.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-24","7/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-06-01","","","2024-12-03","Received confirmation via delegated roster from Emily Starr 11/22/2024. Provider participating 11/4/2024. AS"]
["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","","Ambetter","Participating","Enrollment Complete","2023-07-01","","","2025-04-14","Received email from SHP confirming location linked to provider's record.  Provider's participating with Superior Medicaid, Medicare and Ambetter. PA."]
["David Powell Haynie, MD","1083672778","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-05-01","","","2025-02-25","Received confirmation the provider is linked. MS"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2W8694","","2024-04-16","Reconsideration request for the ICR was APPROVED and the effective date was backdated to 6/18/2023. MS"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-06-01","","","2025-02-25","Received email from Karen Avalos, confirming provider is linked to TIN/location combination, eff.  06/01/2024. PA."]
["David Powell Haynie, MD","1083672778","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-11-15","2840278","","2023-11-30","Received enrollment confirmation. MS"]
["David Powell Haynie, MD","1083672778","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["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","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","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-12","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","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"]
["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","Coventry Workers Comp","Participating","Enrollment Complete","2023-06-30","","","2024-04-25","4/25/2024 provider enrolled as of 6/30/2023 via roster. FC"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-01","9695700","","2023-10-24","10.24.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 06/12/2023. Next recredentialing date is 06/12/2026. PIN: 9695700. Servicing location is on file. Payer# 60054. Call ref# 6167813673. - Willie Ravas"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","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","","IMS","Participating","Enrollment Complete","2023-10-01","","","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 10/2/2023.  DCannon"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-06-12","","","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 6/12/2023.  DCannon"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","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","Wellmed","Participating","Enrollment Complete","2023-08-19","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 08/19/2023.  PA"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-08-19","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 08/19/2023.  PA"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 7/20/2023.  DCannon"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","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","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-23",""]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-29","","","2024-01-04","Rcvd welcome letter. Provider is effective 12/29/2023. Jen Videan"]
["Kelly Burrows, FNP","1518292077","47-3465832","tx","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","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."]
["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","","","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","TriCare Standard","Participating","Enrollment Complete","2024-11-26","","","2025-03-04","Provider is confirmed as linked to this location. 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","Application Resubmitted","2023-06-01","2243378","","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"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-06-12","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-06-12","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","","Aetna","Participating","Enrollment Complete","2023-06-01","9695700","","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"]
["Kelly Burrows, FNP","1518292077","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."]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-24","Per Benjamin Richbourg, roster has been successfully loaded. They do not have effective dates for individual providers. The only effective date is the one on the contract. For this contract effective date is 05/23/2023. Jen Videan"]
["Kelly Burrows, FNP","1518292077","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-24","Per Benjamin Richbourg, roster has been successfully loaded. They do not have effective dates for individual providers. The only effective date is the one on the contract. For this contract effective date is 05/23/2023. Jen Videan"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2025-05-05","13954674","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","West Texas Allergy, PA","Medicaid","Participating","Enrollment Complete","2023-05-29","1073983193","","2023-08-21","Dana Bell par effective 05/29/2023 at 5000 Briarwood Ave Midland, TX 79707. Jen Videan"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2023-09-01","1073983193","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/ all locations effective 9/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2023-06-22","1073983193","","2024-08-23","Briarwood Location: Provider is active and linked to this location eff 7/9/2024. 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","Rail Road Medicare","Participating","Enrollment Complete","2023-05-29","Q00516460","CF8499","2023-07-19","7/19/2023 Rcvd RR Medicare approval letter.   PTAN # Q00516460 - effective 5/29/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","667985783","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Dana L Bell, APRN-FNP-BC","1073983193","75-2781652","TX","West Texas Allergy, PA","Superior","Participating","Enrollment Complete","2023-09-01","1073983193","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["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","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-18","both locations. panel is closed. MS"]
["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","Midland Medicine PA","CAQH","Participating","CAQH Reattested","2025-05-08","","","2025-05-08","05/08/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Gallagher","Participating","Enrollment Complete","2023-06-11","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","Midland Medicine PA","USA PPO","Participating","Enrollment Complete","2023-08-01","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to locations/TIN effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","Midland Medicine PA","Liberty Mutual","Participating","Enrollment Complete","2023-06-11","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","Midland Medicine PA","Wellmed","Participating","Enrollment Complete","2023-08-01","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Wellmed","Participating","Enrollment Complete","2023-08-01","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","","Medicare","Participating","Enrollment Complete","2023-06-01","2W9073","","2023-12-08","Received  confirmation of the last name change. MS"]
["Laura Sonnenburg, PA","1003214511","84-2617748","TX","Midland Medicine PA","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","","Caprock (CapStar)","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","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","Midland Inpatient Medical Association","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","HealthSmart PPO","Participating","Enrollment Complete","2023-09-08","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tokkie Orogbemi, CPNP","1790435014","75-2133441","TX","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","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from June has been completed and provider is PAR effective 7/20/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2023-09-19","","","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 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","IMS","Participating","Enrollment Complete","2023-09-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-09-19","","","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 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","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"]
["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","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-24","Pending Aetna approval. MS"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-09-19","","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD","1598182412","75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-09-19","","","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 9/19/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","Permian Cardiology Inc.","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.","First Health Coventry","Participating","Enrollment Complete","","3143820","","2023-11-16","Confirmed enrollment via the payor directory. MS"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","TX","Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2023-08-10","","","2023-08-24","Provider is linked to location effective 8/10. MS"]
["Whitney E Wyers, APRN-FNP-BC","1972003119","27-4061759","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"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-07-10","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to locations/TIN effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","tx","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2023-07-10","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","tx","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2023-07-10","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","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"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-07-10","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","","Aetna","Participating","Enrollment Complete","2023-07-10","8683782","","2024-05-20","5/20/2024- Spoke to DJ A. call ref# 6192837355, 616 N Main st location participating as of 7/10/2023. FC"]
["Taylor Brown, APRN-FNP-BC","1104519057","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"]
["Taylor Brown, APRN-FNP-BC","1104519057","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."]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-07-10","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff. 07/10/2023. PA"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","tx","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-10","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-10","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","4705 Briarwood Ave, 210 West Longview Ave Ste A Bldg A and 6950 Eastridge  are effective 09/01/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-29","","","2024-06-25","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"]
["Taylor Brown, APRN-FNP-BC","1104519057","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"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-06-03","This is a facility enrollment. No credentialing is required for individual providers. Provider will bill services through the group contract. MS"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2023-09-28","Per Michelle Killough provider is effective 08/25/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-07-10","3701694","","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"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-07-10","","","2024-01-31","1/31/2024 Per Humana provider portal provider is PAR and linked to group TIN/locations effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-07-10","","","2024-01-31","1/31/2024 Per Humana provider portal provider is PAR and linked to group TIN/locations effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-07-10","","","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"]
["Taylor Brown, APRN-FNP-BC","1104519057","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."]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-29","008760942","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 9/29/2023.  MPIN # 008760942.  DCannon"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-10","","","2024-07-23","As per Kim Patterson provider participating as of 7/10/2023 received via email. FC"]
["Taylor Brown, APRN-FNP-BC","1104519057","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"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-30","15954818","","2025-04-30","04/30/2025 CAQH Reattested per email-all information is correct and up to date-dvineyard"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-30","15954818","","2025-04-30","04/30/2025 CAQH Reattested per email-all information is correct and up to date-dvineyard"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-08-16",""]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-07-10","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-08-23","Provider is linked with Briarwood and Longview locations effective 8/16. MS"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/2023. MS"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/2023. MS"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-11-05","Revalidation completed. MS"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","tx","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-08","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 9/1/2024\n6301 Andrews Hwy eff. 5/6/2024\n616 N Main St.  & 6950 Eastridge Rd. Eff. 7/10/2023\n4705 Briarwood Ave eff. 10/8/2024. AS"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-08","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 9/1/2024\n6301 Andrews Hwy eff. 5/6/2024\n616 N Main St.  & 6950 Eastridge Rd. Eff. 7/10/2023\n4705 Briarwood Ave eff. 10/8/2024. AS"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-01-17","Per providerrelations@primehealthservices.comYour request has been received and being processed accordingly. However, at this time, I have no updates as to when the directory will be updated with the location add. \nPlease note, all Physicians/locations billing under the TIN you provided are subject to the terms of the PPO agreement and considered in network upon billing with the TIN.  Contract effective date 05/23/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Taylor Brown. Effective 12/05/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Taylor Brown. Effective 12/05/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC","1104519057","47-3465832","tx","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-07-10","8683782","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 7/10/2023. FC"]
["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","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-10-06","","","2023-10-09","Received confirmation email. Attached. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","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","","","2023-10-20","Provider is linked to Florida Ave location .MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-10-20","Provider is linked to the Rosalind location. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC","1215633011","83-0358685","TX","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","Humana","Participating","Enrollment Complete","2023-08-22","","","2023-12-28","12/28/2023 Per Humana online web portal 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","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","Amerigroup","Participating","Enrollment Complete","2023-08-22","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Madhusmita Panda, MD","1134756364","75-2656723","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"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-24",""]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2023-09-29","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-09-29","0037","","2023-10-19","10.18.2023 S/W Kathy of TriCare Standard @ 1-800-444-5445 and transferred me over to the WPS Department and spoke to Shay. Per rep, Provider is certified with TriCare on 09/28/2023 and in network with Tricare and linked to the group and TIN# effective 02/20/2013. No next recredentialing date available. PIN: 0037. Servicing location is on file. Payer# trest. Call ref# Shay10182023."]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-09-24","Q00602400","","2023-11-16","Received confirmation. MS"]
["Madhusmita Panda, MD","1134756364","75-2656723","TX","","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","Zurich","Thru Other Payor","Thru Other Payor","2024-03-01","","","2024-10-01","See Coventry payor line for updates. Jen Videan"]
["Abbie Estes, PA","1952088411","46-0950925","TX","","Amerigroup","Participating","Enrollment Complete","2023-09-08","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Abbie Estes, PA","1952088411","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","2023-07-10","1952088411","","2024-06-04","Approval ltr rcvd. Effective 07/10/2023. Jen Videan"]
["Abbie Estes, PA","1952088411","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-08-07","","","2023-11-20","participating, please see Alliance WC for current notes. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2025-02-09","Per providerdata@careworks.com, address has been added. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","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","","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-11-05","Revalidation completed. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-07-26","","","2024-10-14","Per Dee Dee Johnson at Texas Mutual site visit completed on 07/26/2024. Jen Videan"]
["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","Aetna","Participating","Enrollment Complete","2023-09-08","6474406","","2023-10-24","10.24.2023 S/W JoeO of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/08/2023. No next recredentialing date available. PIN: 6474406. Servicing location is on file. Payer# 60054. Call ref# 6167817975. - Willie Ravas"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","","","","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"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-09-22","","","2024-02-16","Per Michelle Killough @ Alliance WC provider is effective 09/22/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","","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","HealthSmart PPO","Participating","Enrollment Complete","2023-09-08","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","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","Multiplan","Opt Out","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","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"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-08","3746844","","2023-11-20","11/20/2023 S/W James of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/8/2023. Provider ID 3746844. Physical locations are on file. Call ref#:773110. - DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","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","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."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","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."]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-12","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","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","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","tx","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","Humana","Participating","Enrollment Complete","2023-09-08","","","2023-12-28","12/28/2023 Per Humana online web portal provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","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","Alliance WC","Participating","Enrollment Complete","2024-05-30","","","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"]
["Tiffany Nicol Bynum, APRN-FNP-BC","1376006403","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-20","WTUC has an active Ancillary Contract in effect, which means any midlevel will not require credentialing and all services will be billed under the group contract. MS"]
["Rony Ninan, MD","1750526182","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-10-09","","","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 10/9/2023.  DCannon"]
["Rony Ninan, MD","1750526182","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-09-01","Q00658585","CE1588","2024-02-07","Received approval letter. MS"]
["Rony Ninan, MD","1750526182","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to locations/TIN effective 9/1/2023.  DCannon"]
["Rony Ninan, MD","1750526182","75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-10-09","","","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 10/9/2023.  DCannon"]
["Rony Ninan, MD","1750526182","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-10-09","","","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 10/9/2023.  DCannon"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","Midland Inpatient Medical Association","Amerigroup","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","Cigna","Participating","Enrollment Complete","2023-12-05","9594034","","2024-01-02","Received confirmation of enrollment. MS"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-02","","","2023-11-03","11/3/2023 Per email received from Scott & White provider is PAR and linked to group effective 11/2/2023.  DCannon"]
["Rajnarsing R Chennamaneni, MD","1164689634","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Add Info Submitted","2023-11-06","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["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","Cigna","Participating","Enrollment Complete","2024-05-03","5056023","","2024-05-06","Received confirmation of enrollment. MS"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2023-09-08","1083394977","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","West Texas Allergy, PA","Tricare Prime","Panel Closed","Panel Closed","2023-10-30","","","2024-09-18","19 st location"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","1083394977","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2025-04-30","16016463","","2025-04-30","04/30/2025 CAQH Reattested per email-all information is correct and up to date-dvineyard"]
["Amanda Dee Flores, APRN-FNP-BC","1083394977","75-2781652","TX","West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2023-09-08","1083394977","","2023-12-22","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 9/8/2023.  DCannon"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-08","","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/8/2023. \nMPIN # 004473172.  DCannon"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-08","004473172","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/8/2023. \nMPIN # 004473172.  DCannon"]
["Ankit Ashwin Patel, MD","1083979322","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-11-08","","","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 11/8/2023.  DCannon"]
["Billy S Gao, MD","1699092304","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff.  11/06/2023 and linked to TIN. PA"]
["Billy S Gao, MD","1699092304","75-2656723","TX","Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Billy S Gao, MD","1699092304","75-2656723","TX","Premier Family Care, Inc","United Health Care","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 # 006259813.  DCannon"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2023-11-15","Per the payor, the panel is closed for new enrollments. MS"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","","First Health Coventry","Participating","Enrollment Complete","2024-01-01","","","2024-06-25","As per Teresita (call ref# 1105034) provider participating as of 1/1/2024, listed as Family Practice. FC"]
["Sudhir K Chiluka, MD","1912452053","47-5554737","TX","","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","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2024-01-17","","","2024-01-08","1/8/2024 Rcvd email from Scott & White that provider is PAR and linked to group TIN/location effective 1/17/2024.  DCannon"]
["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","TriCare Standard","Participating","Enrollment Complete","2023-09-25","","","2023-09-28","Provider is enrolled with the Florida location effective 9/25. MS"]
["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","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"]
["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","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","HealthSmart PPO","Participating","Enrollment Complete","2023-11-06","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023, linked to TIN and the following locations 4214 Andrews HWY, 801 E Florida Ave, and 400 Rosalind Redfern.  PA"]
["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"]
["Kristen Grace Schlemeyer, PA","1790315737","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"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-10-01","Q00656144","","2024-07-01","Main St. location approved 6/10/24. MS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","tx","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-10-01","Q00656144","","2024-07-01","Main St. location approved 6/10/24. MS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-07-26","","","2024-10-14","Per Dee Dee Johnson at Texas Mutual site visit completed on 07/26/2024. Jen Videan"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-16","Confirmed provider is linked to all Briarwood and Longview locations effective 10/9/23. MS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-11-06","","","2024-05-20","5/20/2024- Spoke to Zach B call ref#2192834359 616 N Main St location eff as of 11/6/2023. FC"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","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","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-11-27","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","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","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."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-05-31","Facility Enrollment. Providers services are billed through the facility, not an individual claim. MS"]
["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","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","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","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","2025-05-08","","","2025-05-08","05/08/2025 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","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","Texas Mutual","Participating","Enrollment Complete","2023-12-01","","","2023-12-04","Enrollment complete for 4705 Briarwood, 6950 Eastridge and 210 W Longview. Effective 12/01/2023. Jen Videan"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-02-12","","","2024-02-13","Welcome ltr rcvd. Provider effective 02/12/2024. Jen Videan"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","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 eff. 11/6/2023\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"]
["Kristen Grace Schlemeyer, PA","1790315737","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Neel N Shah, MD","1861752529","75-2656723","TX","Premier Family Care, 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: 400 Rosalind Redfern Grover PKWY,  Suite 120. PA"]
["Neel N Shah, MD","1861752529","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-02-05","","","2024-03-21","03/21/2024 - received email confirmation from Karen Avalos (kavalos@ghn-mci.com), provider is PAR, eff. 02/05/2024. PA"]
["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","Premier Family Care, Inc","Amerigroup","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","Rail Road Medicare","Participating","Enrollment Complete","2023-10-01","Q00615975","","2023-12-07","Received approval letter. MS"]
["Jeremy Davis Dominguez, PA","1841508462","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"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-11-27","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","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"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","2231549","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","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","","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-26","Longview location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","tx","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","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2024-02-07","Confirmed provider is linked to Main St. location eff 1/19/2024. MS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2024-02-07","Confirmed provider is linked to Main St. location eff 1/19/2024. MS"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-15","","","2025-04-15","04/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Jeremy Davis Dominguez, PA","1841508462","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. FC"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2024-01-23","00390310977","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/23/2024. PA."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-11-06","003261515","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 11/06/2023. PA."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-03-20","","","2024-03-21","Approval ltr rcvd. Provider effective 03/20/2024. Jen Videan"]
["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","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-02-12","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["Jeremy Davis Dominguez, PA","1841508462","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"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-10","","","2024-07-01","Location has been linked to the group record which rolls to the individual providers record as well. There is no further enrollment needed. MS"]
["Jeremy Davis Dominguez, PA","1841508462","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"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","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","Aetna","Participating","Enrollment Complete","2023-11-06","","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 11/6/2023. FC"]
["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","","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","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."]
["Jeremy Davis Dominguez, PA","1841508462","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-11-06","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 11/06/2023. PA."]
["Alma Martinez, APRN-FNP-BC","1376149153","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."]
["Alma Martinez, APRN-FNP-BC","1376149153","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"]
["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","Alliance WC","Participating","Enrollment Complete","2024-05-28","","","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"]
["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","Alliance WC","Participating","Enrollment Complete","2024-01-19","","","2024-01-29","Alliance WC approval letter rcvd. Provider effective 01/19/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-21","","","2025-03-10","Received confirmation provider participating as of 8/21/2024, spoke to Theresa call ref#1455874. FC"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1376149153","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","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","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","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["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","Aetna","Participating","Application Resubmitted","2024-02-01","","","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"]
["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","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","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","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. 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","Rail Road Medicare","Participating","Enrollment Complete","2023-11-01","Q00771231","DX4335","2024-06-26","Enrollment welcome letter received. MS"]
["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","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Longview, Briarwood, and Eastridge locations. MS"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","Texas Municipal League","Participating","Enrollment Complete","2024-01-19","","","2024-01-29","Please see status updates under Alliance WC payor line. Jen Videan"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","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","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-04","Enrollment complete for 4705 Briarwood, 6950 Eastridge and 210 W Longview. Effective 12/01/2023. Jen Videan"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-08","15380393","","2025-05-08","05/08/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-08","15380393","","2025-05-08","05/08/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Alma Martinez, APRN-FNP-BC","1376149153","47-3465832","TX","WesTex Urgent Care, PLLC","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","Wellcare","Participating","Enrollment Complete","2024-04-01","","","2024-06-04","Received email confirmation from shpdelegation@superiorhealthplan.com provider is PAR, linked to TIN and locations, eff. 04/01/2024. PA"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-02-27","","","2024-04-29","ReCredentialing has been completed eff 2/27/24. MS"]
["Bailey Bergman, PA","1447851639","75-2656723","TX","","Caprock (CapStar)","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","Multiplan","Participating","Enrollment Complete","2024-03-11","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 03/11/2024. PA."]
["Bailey Bergman, PA","1447851639","75-2656723","TX","","Multiplan","Participating","Re-Credentialing","2024-03-11","","","2025-02-14","Submitted recredentialing via delegated roster on 2/14/2025. FC"]
["Brittany P Price, RD","1922875160","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-01-08","","","2024-06-03","Received email confirmation from Karen Avalos (kavalos@ghn-mci.com ) provider is PAR and linked to TIN/location, eff. 1/08/2024"]
["Brittany P Price, RD","1922875160","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-07-02","","","2024-09-19","Approval ltr rcvd. 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","","Multiplan","Participating","Application Resubmitted","2024-02-05","","","2025-01-15","Application resubmitted via delegated roster. AS"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2024-02-05","","","2024-05-24","Par through Multiplan enrollment, eff. 02/05/2024. PA"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","","BCBSTX","Participating","Enrollment Complete","2024-01-26","","","2024-02-26","Received email confirmation from Karina Vasquez provider is PAR with BCBSTX, eff. 1/26/2024. Provider is PAR w/ the following: BAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nMCH - Medicare Advantage HMO\nPMC - Medicare Advantage PPO\nSNP - Dual Eligible Special Needs Plan\nWEL - WellMed MA HMO"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","Premier Family Care, Inc","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","","Tricare Prime","Participating","Enrollment Complete","2024-01-15","","","2024-04-29","Provider's recert has been approved eff 1/15/2024. MS"]
["Carrie M Watson, APRN-NP","1700513504","75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-15","","","2024-01-19","Received confirmation of approval. MS"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","Ambetter","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","Galaxy Health","Participating","Confirm Par Status","2024-05-05","","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of 05/05/2024. PA."]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","","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","","Aetna","Participating","Application Resubmitted","2024-02-05","8559878","","2025-01-15","Application resubmitted via delegated roster. AS"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2024-03-01","","","2024-03-08","Rcvd approval letter. Provider effective 03/01/2024. Jen Videan"]
["Alberto Fernandez, PA","1912697970","46-3131679","TX","Midland Texas Orthopedic Group Inc","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"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2024-08-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 8/5/2024.  PA"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-08-05","","","2024-10-07","Received confirmation via email, provider participating as of 8/5/2024. FC"]
["Nikolas V St Cyr, MD","1538659487","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2024-07-29","Q00774162","CE1588","2024-07-01","Provider has been approved. 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","Medicare","Participating","Enrollment Complete","2024-07-01","6Q7671","","2024-05-20","Received enrollment confirmation. MS"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","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"]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-09-09","","","2024-10-04","Received email confirmation Sept roster is processed. Provider is participating, linked to TIN and location, effective 9/9/2024. PA."]
["Rathnavali Katragadda, MD","1750885075","75-2656723","TX","Premier Family Care, Inc","Wellcare","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","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","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","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","United Health Care","Participating","Enrollment Complete","2024-09-09","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 9/9/2024.  PA"]
["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","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","Texas Mutual","Participating","Enrollment Complete","2024-05-01","1184490161","","2024-05-09","Approval ltr rcvd. Effective 05/01/2024. Jen Videan"]
["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","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."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-28","","","2024-06-25","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Caroline 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","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"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-04-05","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  04/05/2024.  PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","In Process","Application Resubmitted","2024-03-06","","","2025-04-21","4/21: Application resubmitted and AO Signature Page uploaded. App was sent to the provider for signature. T042120250003544 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","2025-04-30","","","2025-04-30","4/30/2025 CAQH Reattested per email-all information is correct and up to date-dvineyard"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-30","","","2025-04-30","4/30/2025 CAQH Reattested per email-all information is correct and up to date-dvineyard"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","Tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-03-07","","","2024-03-12","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Application Resubmitted","","","","2025-03-18","Application resubmitted. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Application Resubmitted","","","","2025-03-18","Application resubmitted. 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","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","","2024-05-20","5/20/2024- Spoke to Max C call ref# 6192813282 provider participating with all 5 locations effective as of 4/5/2024, provider listed as a SPEC. 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","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","First Health Coventry","Participating","Enrollment Complete","2024-04-05","","","2024-06-26","Spoke to Rick P call ref# 1106851 he indicated provider is participating as of 4/5/2024 with all 5 locations. FC"]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-04-05","","","2024-06-26","Spoke to Rick P call ref# 1106851 he indicated provider is participating as of 4/5/2024 with all 5 locations. 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","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","Humana","Participating","Enrollment Complete","2024-06-28","","","2024-07-31","Received email confirmation location has been added, eff. 06/28/2024. PA."]
["Caroline G Clements, APRN-FNP-BC","1184490161","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-04-12","","","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","Rail Road Medicare","Participating","Enrollment Complete","2024-03-06","Q00724731","","2024-04-25","Received confirmation of enrollment. MS"]
["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","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","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"]
["Robert John Cornell, MD","1457331803","26-3789190","TX","Permian Physician Services","Cigna","Participating","Enrollment Complete","2024-04-01","0224388","","2024-08-09","Received enrollment complete confirmation email. MS"]
["Robert John Cornell, MD","1457331803","75-1997880","TX","Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2024-04-01","","","2024-08-29","Received confirmation from Cassandra Dunagon provider participating as of 4/1/2024 listed as a Urologist. FC"]
["Robert John Cornell, MD","1457331803","75-1997880","TX","Andrews County Hospital District","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-05-01","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Robert John Cornell, MD","1457331803","26-3789190","TX","Permian Physician Services","Wellmed","Participating","Enrollment Complete","2024-01-03","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 1/3/2024.  PA"]
["Robert John Cornell, MD","1457331803","26-3789190","TX","Permian Physician Services","Aetna","Participating","Enrollment Complete","2024-05-01","7616472","","2024-11-20","Provider is linked to this location per the directory. MS"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2024-09-01","","","2024-08-28","Approval ltr rcvd. Effective 09/01/2024. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-03-04","Received confirmation via email from First Health, provider par as of 10/1/2024. FC"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","BCBSTX","Participating","Enrollment Complete","2024-07-12","8WL530","","2024-07-11","Received email confirmation provider is PAR and linked to TIN/location, eff. 7/12/2024. Provider is participating with the following products: BAV - Blue Advantage HMO\nHMO - Blue Essentials\nBCA - BlueChoice PPO\nHME - Health Select\nMCH - Medicare Advantage HMO\nPMC - Medicare Advantage PPO\nWEL - WellMed MA HMO\nSNP - Dual Eligible Special Needs Plan. PA."]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2024-09-18","Approval ltr rcvd. Effective 09/18/2024. Jen Videan"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 6/10/2024. AS"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-09-09","","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of 09/09/2024. PA."]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","Rail Road Medicare","Participating","Enrollment Complete","2024-08-11","","","2024-08-23","Provider is active under this TIN with RR MCR. MS"]
["Patrick M Brennan, DO","1295354264","46-3131679","TX","","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["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","Scott&White (First Care)","Participating","Enrollment Complete","2024-07-10","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff.  07/10/2024. PA."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-29","","","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"]
["Stacy J Hernandez, APRN-NP","1548026099","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."]
["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","Medicare","In Process","Enrollment Complete","2024-03-15","6P6674","","2024-04-30","Received welcome letter eff 3/15/24. MS"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","In Process","Payor Follow Up","2024-03-15","6P6674","","2025-03-21","Application was signed on 3/5 and is processing. MS"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-08","","","2024-04-11","Per updates@primehealthservices.com, our systems have been updated with request to add Stacy Hernandez NPI 1548026099. Effective date is contract date of 05/08/2023. Jen Videan"]
["Stacy J Hernandez, APRN-NP","1548026099","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."]
["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","","","","2024-11-14","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","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."]
["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","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","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"]
["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","TriCare Standard","Participating","Enrollment Complete","2024-05-14","","","2024-07-02","Provider is linked to all 5 locations eff 5/14/2024. 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","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 9/1/2024\n6950 Eastridge Rd,  6301 Andrews Hwy 10/4/2024.\n616 N Main St, 4705 Briarwood Ave 5/6/2024\nAS"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","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."]
["Stacy J Hernandez, APRN-NP","1548026099","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."]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-02-12","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["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","Tricare Prime","Panel Closed","Panel Closed","2024-04-08","","","2024-04-09","Location is not Tricare Credentialed, and the panel is closed for new providers. MS"]
["Stacy J Hernandez, APRN-NP","1548026099","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-05-06","","","2024-07-30","Received product roster. 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","Sedgwick","Participating","Enrollment Complete","2024-07-22","","","2024-07-24","Approval ltr rcvd. Effective 07/22/2024. Jen Videan"]
["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"]
["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","BCBSTX","Participating","Enrollment Complete","2024-04-22","","","2024-04-24","Received email confirmation provider is PAR, eff. 04/22/2024, participating with the following networks: BAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA."]
["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","Sedgwick","Participating","Enrollment Complete","2024-05-29","","","2024-08-05","Approval ltr rcvd. Effective 07/22/2024. Jen Videan"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-05-06","","","2025-02-18","Received verbal confirmation from Karen Avalos that the provider has been reinstated and is linked to the following locations:\n\n4705 Briarwood Ave, Midland, TX 79707 – Effective 05/06/2024\n616 N Main St, Andrews, TX 79714 – Effective 05/06/2024\n6301 Andrews Hwy, Midland, TX 79706 – Effective 05/06/2024\n6950 Eastridge Rd, Odessa, TX 79765 – Effective 05/06/2024"]
["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","Texas Mutual","Participating","Enrollment Complete","2024-06-01","1093796435","","2024-06-11","Approval ltr rcvd. Effective 06/01/2024. Jen Videan"]
["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","Multiplan","Opt Out","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["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","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."]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-04-26","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 4/26/2024.  PA"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-04-26","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 4/26/2024.  PA"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-05-06","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 05/06/2024. 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","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Teresa L Callahan, NP","1093796435","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."]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","","","2024-07-24","Approval ltr rcvd. Effective 07/22/2024. Jen Videan"]
["Teresa L Callahan, NP","1093796435","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-04-24","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","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","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","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"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-04-26","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 4/26/2024.  PA"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2019-03-13","","","2024-04-24","Received enrollment confirmation eff 3/13/24. MS"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","2025-04-15","","","2025-04-15","04/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Teresa L Callahan, NP","1093796435","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-06-06","","","2025-04-29","Received email from HPDelegation, confirming provider is participating, linked to TIN/location, eff. 06/06/2024. PA."]
["Teresa L Callahan, NP","1093796435","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"]
["Olivia O Infante, APRN-FNP-BC","1447899679","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."]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-05-10","Q00744975","DX4335","2024-05-22","Received confirmation. MS"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","tx","WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-05-15","","","2024-05-15","Received email confirmation provider is PAR, eff. 05/15/2024, TIN and all locations linked, participating with the following networks: BCA - BlueChoice PPO\nBAV - Blue Advantage HMO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA"]
["Olivia O Infante, APRN-FNP-BC","1447899679","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"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","tx","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-05-10","","","2025-03-06","Main St location PTAN 6P6053 was linked eff 12/22/2024. MS"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","tx","WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-29","Received email confirmation provider is par and linked to TIN/locations, eff. 07/11/2024. PA."]
["Olivia O Infante, APRN-FNP-BC","1447899679","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."]
["Olivia O Infante, APRN-FNP-BC","1447899679","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."]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Pending Other Enrollment","Application Resubmitted","","","","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"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-11-26","Provider is linked to Andrews Hwy and Main St. locations. mS"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2025-03-04","Eastridge Location approved eff 4/29/24. MS"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Action Needed","2024-09-13","","","2024-12-17","Roster has provider's last name listed as \"Ortiz\". Need to submit updated name. PA."]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","Participating","Action Needed","2024-09-13","","","2024-12-17","Roster has provider's last name listed as \"Ortiz\". Need to submit updated name. PA."]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 6/10//2024. AS"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 6/10/2024. AS"]
["Olivia O Infante, APRN-FNP-BC","1447899679","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."]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-04-28","Facility Contract - No individual enrollment required as all billed services are done through the group, not the individual. MS"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2024-10-08","Approval ltr rcvd. Effective 09/18/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-dvineyard"]
["Olivia O Infante, APRN-FNP-BC","1447899679","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\n6950 Eastridge Rd, 616 N Main St, 6301 Andrews Hwy, 4705 Briarwood Ave eff. 6/10/2024. AS"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-07-10","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff. 07/10/2024. PA."]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-04-26","","","2024-08-09","Welcome ltr rcvd. Effective 08/01/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-04-28","Panel is closed to new providers. MS"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-06-10","6324539","","2024-10-29","Received confirmation via deleagted roster from Brandy Smith Provider participating effective06/10/2024. FC"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-06-10","","","2025-02-18","Received verbal confirmation from Karen Avalos provider reinstated, linked to remaining locations, eff. 06/10/2024. PA"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-08-06","","","2024-08-06","Approval ltr rcvd. Effective 08/06/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC","1447899679","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-06-03","This is a facility enrollment. No credentialing is required for individual providers. Provider will bill services through the group contract. MS"]
["Rizwan Asim, MD","1205287646","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."]
["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","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 10/7/2024. FC"]
["Rizwan Asim, MD","1205287646","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"]
["Kwame B Agyeman, MD","1285863753","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is linked to this location eff 6/17/2024. MS"]
["Kwame B Agyeman, MD","1285863753","47-5554737","TX","Midland Inpatient Medical Association","CAQH","In Process","CAQH Reattested","2025-05-05","","","2025-05-05","05/05/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Hamza Muhammad Tola, MD","1154818342","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2024-09-06","4980702","","2024-11-25","Provider approved. MS"]
["Hamza Muhammad Tola, MD","1154818342","47-5554737","TX","Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2024-09-06","","","2025-02-21","Approval ltr rcvd. Effective 09/06/2024. Jen Videan"]
["John W Romeo, MD","1447661764","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"]
["John W Romeo, MD","1447661764","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2024-10-01","","","2025-02-05","Received confirmation via phone, provider participating as of 10/1/2024, call ref#1404564 spoke to Stacey. FC"]
["Pierre M 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 M Agnant, MD","1669868568","47-5554737","TX","Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-02","This location is not Tricare credentialed and the panel is closed. MS"]
["Pierre M Agnant, MD","1669868568","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."]
["Ugochukwu Ikechi Maduforo, MD","1447630033","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"]
["Ugochukwu Ikechi Maduforo, MD","1447630033","47-5554737","TX","Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2024-10-07","","","2025-02-04","Received confirmation via email from LaNetrice Myart, provider participating as of 10/7/2024. FC"]
["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","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2024-10-11","7D0806","519061","2024-12-10","Received welcome letter. mS"]
["Nadeem Jaffer, MD","1427302025","47-5554737","TX","Midland Inpatient Medical Association","CAQH","In Process","CAQH Reattested","2025-04-14","","","2025-04-14","04/14/2025 CAQH Reattested-all information is correct and up to date-updated CAQH UN/PW in cactus from email that provider updated it-dvineyard"]
["Sahil Batta, MD","1801324306","47-5554737","TX","Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-31","Panel in closed. MS"]
["Sahil Batta, MD","1801324306","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."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2025-04-21","","","2025-04-21","04/21/2025 CAQH Reattested-updated DEA exp and uploaded doc-dvineyard"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","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","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","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-05-22","Group holds a facility contract. Midlevels will bill services under the group info, not individually. MS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-11-27","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","In Process","Payor Follow Up","2024-05-10","6S2250","","2025-03-21","Provider signed app on 3/5 and application is processing. 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","Rail Road Medicare","Participating","Enrollment Complete","2024-05-10","Q00774238","DX4335","2024-07-01","Provider has been linked to group. MS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-30","","","2024-10-01","Welcome ltr rcvd. Effective 08/23/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","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."]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-21","","","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","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","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","United Health Care","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","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","Tricare Prime","Panel Closed","Panel Closed","","","","2024-05-22","WTUC is not Tricare Credentialed and the network is not accepting new providers. MS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","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.  07/01/2024.  PA."]
["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","Texas Municipal League","Participating","Enrollment Complete","2024-05-30","","","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","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Mary Kay Ragan, APRN-FNP-BC","1366816829","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Dharti Rajesh Patel, MD","1609364777","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2024-11-04","","","2025-02-03","Received  confirmation via email from Karen Avalos, provider participating as of 11/4/2024. FC"]
["Dharti Rajesh Patel, MD","1609364777","47-5554737","TX","Midland Inpatient Medical Association","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."]
["Dharti Rajesh Patel, MD","1609364777","47-5554737","TX","Midland Inpatient Medical Association","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. PA."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","United Health Care","In Process","Payor Follow Up","","","","2025-05-27","Per UHC rep Alondra, provider is OON. Will have provider's application resubmitted via roster submission."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","United Health Care","In Process","Payor Follow Up","","","","2025-05-27","Per UHC rep Alondra, provider is OON. Will have provider's application resubmitted via roster submission."]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","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"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","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"]
["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 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","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"]
["Emma E Patterson, PA","1922775287","83-0358685","TX","Midland Community Healthcare Services","Wellcare","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","IMS","Participating","Enrollment Complete","2024-07-01","","","2024-08-30","Received confirmation via email from German Aviles provider participating eff date 7/1/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","Wellmed","Participating","Enrollment Complete","2024-08-05","1598517369","","2024-10-17","Per UHC rep Jessica, via online chat- ref# 04809568, provider is participating and linked to TIN/locations, eff. 8/05/2024. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","Wellcare","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, PA","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, PA","Omni PPO","Participating","Enrollment Complete","2024-08-05","","","2024-10-04","Received confirmation via email from German Aviles, provider participating as of 8/5/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2024-07-17","1691234","","2024-07-18","Received enrollment confirmation. MS"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, PA","United Health Care","Participating","Enrollment Complete","2024-08-05","9242351","","2024-10-17","Per UHC rep Jessica, via online chat- ref# 04809568, provider is participating and linked to TIN/locations, eff. 8/05/2024. PA."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","Boon Chapman","Participating","Thru Other Payor","2024-08-01","","","2024-12-03","Boon-Chapman serves as a third-party administrator for Aetna and is accessible via the Aetna network. PA."]
["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","IMS","Participating","Enrollment Complete","2024-08-05","","","2024-10-04","Received confirmation via email from German Aviles, provider participating as of 8/5/2024. FC"]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, PA","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","Scott&White (First Care)","Participating","Enrollment Complete","2024-09-05","1598517369","","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."]
["Audrey K Allen, APRN-FNP-C","1598517369","75-2781652","TX","West Texas Allergy, Lubbock, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-09-05","1598517369","","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","Tricare Prime","Panel Closed","Panel Closed","","","","2024-07-03","This location is not Tricare credentialed, and the panel is closed at this time. Nothing further is needed. MS"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Wellmed","Participating","Enrollment Complete","2024-08-05","1144933367","","2024-10-17","Per UHC rep Jessica, via online chat- ref# 04809568, provider is participating and linked to TIN/locations, eff. 8/05/2024. PA."]
["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","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."]
["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","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","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"]
["Jennifer F Blackerby, PA","1144933367","75-2781652","TX","West Texas Allergy, PA","Amerigroup","Participating","Enrollment Complete","2024-08-05","","","2024-10-01","Received confirmation via email, provider participating as of 8/5/2024. FC"]
["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","Medicaid","Participating","Enrollment Complete","2024-07-01","1144933367","","2025-01-29","Approval ltr rcvd. Effective 07/01/2024. Jen Videan"]
["Amanda L Marshall, MD","1518195346","47-5554737","TX","Midland Inpatient Medical Association","Ambetter","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"]
["George J Germanos, MD","1144858390","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"]
["George J Germanos, MD","1144858390","47-5554737","TX","Midland Inpatient Medical Association","CAQH","In House Enrollment","In House Enrollment","2025-06-05","","","2025-06-05","06/05/2025 Per email from Leslie provider wants to maintain his own CAQH profile and email has been saved to doc's-dvineyard"]
["George J Germanos, MD","1144858390","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."]
["Aliaksandr Savitski, MD","1053654863","47-5554737","TX","Midland Inpatient Medical Association","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/7/2024. PA."]
["Aliaksandr Savitski, MD","1053654863","47-5554737","TX","Midland Inpatient Medical Association","Ambetter","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"]
["Aliaksandr Savitski, MD","1053654863","47-5554737","TX","Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-16","location is not Tricare certified and the panel is closed to new enrollments. MS"]
["Samantha A Hall, DPM","1942592803","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2025-01-01","Q00961297","CE1588","2025-02-20","Enrollment Confirmed. MS"]
["Samantha A Hall, DPM","1942592803","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"]
["Samantha A Hall, DPM","1942592803","75-2656723","TX","Premier Family Care, Inc","Wellmed","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."]
["Aimel Azizi, MD","1144480997","47-5554737","TX","Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2024-11-04","","","2025-03-14","Received product roster from UHC,  provider is listed PAR, linked to TIN/location, eff. 11/04/2024. PA."]
["Aimel Azizi, MD","1144480997","47-5554737","TX","Midland Inpatient Medical Association","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","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","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","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","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","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","","","2024-12-11","Approval ltr rcvd. Effective 12/01/2024. Jen Videan"]
["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","Medicare","Participating","Enrollment Complete","2024-11-01","7B3481","","2025-03-21","Provider is linked to PTAN 6P6053. 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","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","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","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","In Process","Add Info Submitted","","","","2025-02-14","Submitted application again via delegated roster on 2/14/2025. FC"]
["Shawndra D Moore, APRN-FNP-BC","1821867714","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","In Process","Add Info Submitted","","","","2025-02-14","Submitted application again via delegated roster on 2/14/2025. FC"]
["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","Amerigroup","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["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","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","2025-05-13","","","2025-05-13","05/13/2025 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","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","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","","","","2024-10-16","This group has an active ancillary contract. No midlevels will need to be credentialed and all services are billed through the group. MS"]
["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","Texas Municipal League","Participating","Enrollment Complete","","","","2025-02-03","Please see status under Alliance WC payor line. Jen Videan"]
["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","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-18","Per updates@primehealthservices.com provider has been loaded. Jen Videan"]
["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","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."]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","Midland Texas Orthopedic Group Inc","BCBSTX","Participating","Enrollment Complete","2024-12-20","","","2024-12-24","Received email confirming provider is par and linked to TIN/location, eff 12/20/24, in the following networks: Blue Advantage HMO, BlueChoice PPO, Health Select, Blue Essentials, Medicare Advantage PPO, Dual Eligible Special Needs Plan, Medicare Advantage HMO, and WellMed MA HMO. PA."]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2025-03-01","","","2025-02-24","Received email from Scarlett A, provider is par, linked to TIN/location, eff. 03/01/2025. PA."]
["Ashley R Smith, APRN-FNP-BC","1952134223","46-3131679","TX","Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2024-11-04","","","2025-01-21","Received confirmation via email from Jessica Bess that provider is participating. AS"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2024-11-01","","","2025-05-19","Received confirmation via email from Aimeleen Diamse from First Health, provider particiapating as of 11/1/2024. FC"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2024-11-04","8059727","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 11/4/2024. FC"]
["Gloria A Horner, PA","1932827433","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2024-11-04","8059727","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 11/4/2024. FC"]
["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","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"]
["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","","Scott&White (First Care)","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission. PA."]
["Kirubel E Adafre, MD","1700381852","47-5554737","TX","","Aetna","In Process","Application Submitted","","","","2025-05-15","Application submitted via delegated roster. FC"]
["Kirubel E Adafre, MD","1700381852","47-5554737","TX","Midland Inpatient Medical Association","Superior","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission. PA."]
["Kirubel E Adafre, MD","1700381852","47-5554737","TX","","Wellcare","In Process","Application Submitted","","","","2025-05-15","Submitted application via roster submission. Pending Superior enrollment. PA."]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","","PPHP","Participating","Enrollment Complete","2025-02-03","","","2025-03-24","Received email confirmation provider is par, linked to TIN/location, eff. 2/3/2025. PA."]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","","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","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2025-02-03","","","2025-04-14","Received email from Karen Avalos confirming February roster was processed. Provider par, eff. 02/03/2025. PA."]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2025-03-01","7J1290","0008AH","2025-04-03","Received welcome letter. MS"]
["Shahrukh Hussain Khan, MD","1659631869","75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2025-03-01","","","2025-04-14","Provider listed PAR per SHP March validation report, eff. 03/01/2025. PA."]
["Evisencia G Mathurin, APRN-NP","1407472129","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","In Process","Pending Medicare","","","","2025-03-10","Pending Medicare approval. MS"]
["Evisencia G Mathurin, APRN-NP","1407472129","47-5554737","TX","Midland Inpatient Medical Association","CAQH","In Process","CAQH Reattested","2025-05-06","","","2025-05-06","05/06/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Raymond A Barlow, II, APRN-NP","1710315106","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","In Process","Add Info Submitted","","","","2025-05-19","Received confirmation from Aimeleen Diamse from First Health,  provider not participating after roster submission I will resubmit in June 2025 roster. FC"]
["Raymond A Barlow, II, APRN-NP","1710315106","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2025-04-07","7J6402","519061","2025-03-13","Recevied welcome letter. MS"]
["Lenita L Hinkle, APRN-NP","1477948636","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2025-04-07","","","2025-05-20","Received email from Humana confirming provider is par, linked to TIN/location, eff. 04/07/2025. PA."]
["Lenita L Hinkle, APRN-NP","1477948636","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"]
["Lenita L Hinkle, APRN-NP","1477948636","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"]
["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","Alliance WC","Participating","Enrollment Complete","2025-04-11","","","2025-05-05","Approval ltr rcvd. Effective 04/11/2025. Jen Videan"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-04-11","","","2025-05-05","Approval ltr rcvd. Effective 04/11/2025. Jen Videan"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","In Process","Payor Receipt Validated","","","","2025-03-07","Received confirmation of receipt. Ref 13957068. 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","","","","2025-05-27","Per UHC rep Helen, ref# 05230154, Medicare contracts not loaded under provider's profile. Will resubmit for inclusion via next roster submission. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Wellmed","In Process","Payor Follow Up","","","","2025-05-27","Per UHC rep Helen, ref# 05230154, Medicare contracts not loaded under provider's profile. Will resubmit for inclusion via next roster submission. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Pending Contracting","","","","2025-02-28","Pending group contracting. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Application Submitted","","","","2025-03-18","Application submitted via email. FC"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","In Process","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","","","2025-04-30","Approval email rcvd. Effective 05/01/2025. Jen Videan"]
["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","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","","","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","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","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","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. 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","","","2025-04-08","Per updates@primehealthservices.com, The provider has been added to the locations effective 05/23/2023 which is the same date as the contract. Jen Videan"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2025-04-22","Per SPNEAST@sedgwickcms.com, your provider(s) credentialing has been received & is being processed by the CVO & we have not yet received back. If our CVO(Symplr) reaches out to you requesting additional information please respond. Jen Videan"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2025-04-22","Per SPNEAST@sedgwickcms.com, your provider(s) credentialing has been received & is being processed by the CVO & we have not yet received back. If our CVO(Symplr) reaches out to you requesting additional information please respond. Jen Videan"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","In Process","CAQH Reattested","2025-04-16","","","2025-04-16","04/16/2025 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","Tricare Prime","In Process","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","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","In Process","Pending Medicare","","","","2025-02-28","Pending Medicare approval. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","In Process","Pending Medicare","","","","2025-02-28","Pending Medicare approval. MS"]
["Sarah Mary Pettyjohn, APRN-NP","1407668734","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2025-05-14","Per Agie_Anyanya@CORVEL.com, provider is still currently showing in processing. Jen Videan"]
["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","Cigna","In Process","Application Submitted","","","","2025-05-28","Submitted email to Medical Onboarding for enrollment submission. MS"]
["Jeanette K Cala, MD","1629718622","75-2656723","TX","","Medicare","In Process","Pending Info/Document","","","","2025-05-29","Provider current has an 855O and in order to submit an 855R, I need to terminate it. I've reached out to the client for confirmation on how they would like to proceed. MS"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2025-04-30","Pending MCR approval. MS"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","TX","WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2025-04-30","Pending MCR approval. MS"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Application Submitted","","","","2025-05-28","Email submitted to mailto:TXMAContracting@CignaHealthcare.com for enrollment submission. mS"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-24","","","2025-04-24","4/24/2025 CAQH Sweep-completed-dvineyard"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-24","","","2025-04-24","4/24/2025 CAQH Sweep-completed-dvineyard"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","TX","WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2025-04-25","Submitted application via pswca.org. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","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","","tx","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2025-04-25","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","TX","WesTex Urgent Care, PLLC","Cigna","In Process","Application Submitted","","","","",""]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","tx","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","","","","2025-04-28","Link not rcvd per previous comment. Emailed TX Mutual again. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","tx","WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2025-04-25","TSCA and required documents emailed to SPNEAST@sedgwickcms.com. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","TX","WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2025-04-25","TSCA and required documents emailed to SPNEAST@sedgwickcms.com. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","TX","WesTex Urgent Care, PLLC","Medicare","In Process","Payor Follow Up","","","","2025-05-01","I've uploaded both signature documents and the application is processing. MS"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","tx","WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2025-04-25","Please see status updates under Alliance WC payor line. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2025-04-25","Please see status updates under Alliance WC payor line. Jen Videan"]
["Hanah Lee Oquindo Pleines, FNP-C","1285403113","","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-04-30","Per updates@primehealthservices.com, the roster has been added effective 05/23/2023 which is the same effective date as the contract. Jen Videan"]
["Rachel Paige Tolbert, APRN-NP","1124826490","","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","","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2025-04-25","Please see status updates under Alliance WC payor line. Jen Videan"]
["Rachel Paige Tolbert, APRN-NP","1124826490","","TX","WesTex Urgent Care, PLLC","Cigna","In Process","Application Submitted","","","","2025-05-29","Submitted enrollment to Medical Onboarding. MS"]
["Rachel Paige Tolbert, APRN-NP","1124826490","","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-04-30","Per updates@primehealthservices.com, the roster has been added effective 05/23/2023 which is the same effective date as the contract. Jen Videan"]
["Rachel Paige Tolbert, APRN-NP","1124826490","","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Application Submitted","","","","2025-05-29","Email submitted for enrollment. MS"]
["Rachel Paige Tolbert, APRN-NP","1124826490","","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Application Submitted","","","","2025-05-29","Email submitted for enrollment. MS"]
["Rachel Paige Tolbert, APRN-NP","1124826490","","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","","TX","WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2025-04-28","TSCA and required documents emailed to SPNEAST@sedgwickcms.com. Jen Videan"]
["Rachel Paige Tolbert, APRN-NP","1124826490","","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-24","","","2025-04-24","04/24/2025 CAQH Sweep-completed-dvineyard"]
["Rachel Paige Tolbert, APRN-NP","1124826490","","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-24","","","2025-04-24","04/24/2025 CAQH Sweep-completed-dvineyard"]
["Rachel Paige Tolbert, APRN-NP","1124826490","","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2025-04-25","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Rachel Paige Tolbert, APRN-NP","1124826490","","TX","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2025-04-28","Per wwtxcontracts@texasmutual.com, we no longer are processing credentialing via email. Please provide the providers full name, NPI and specialty and we’ll send a link out for you to complete the credentialing process online.\nInformation above emailed to TX Mutual, awaiting link. Jen Videan"]
["Rachel Paige Tolbert, APRN-NP","1124826490","","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","","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","","tx","WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2025-04-25","Submitted application via pswca.org. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2025-04-28","Per wwtxcontracts@texasmutual.com, we no longer are processing credentialing via email. Please provide the providers full name, NPI and specialty and we’ll send a link out for you to complete the credentialing process online.\nInformation above emailed to TX Mutual, awaiting link. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Application Submitted","","","","2025-05-29","email submitted to TXMAContracting. MS"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Application Submitted","","","","2025-05-29","email submitted to TXMAContracting. MS"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-04-30","Per updates@primehealthservices.com, the roster has been added effective 05/23/2023 which is the same effective date as the contract. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-04-30","Per updates@primehealthservices.com, the roster has been added effective 05/23/2023 which is the same effective date as the contract. Jen Videan"]
["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","Thru Other Payor","Thru Other Payor","","","","2025-04-25","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","Thru Other Payor","Thru Other Payor","","","","2025-04-25","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","Cigna","In Process","Application Submitted","","","","2025-05-29","email sent to Medical Onboarding. MS"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2025-04-25","Submitted application via pswca.org. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2025-04-25","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2025-05-05","TSCA and required documents emailed to SPNEAST@sedgwickcms.com. Jen Videan"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-25","","","2025-04-25","04/25/2025 CAQH Sweep-completed-dvineyard"]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","2025-06-04","Case# 15858129 still pending per BCBSTX portal. PA."]
["Gaybrielle Laycee Zuniga Marquez, APRN-NP","1639821564","47-3465832","TX","WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","2025-06-04","Case# 15858129 still pending per BCBSTX portal. PA."]
["Margaret Elizabeth O'Neal, FNP","1245067602","","tx","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2025-06-02","Provider does not require credentialing as this is an ancillary contract. MS"]
["Margaret Elizabeth O'Neal, FNP","1245067602","","TX","WesTex Urgent Care, PLLC","Texas Mutual","Provider Load","Provider Load","","","","2025-04-25",""]
["Margaret Elizabeth O'Neal, FNP","1245067602","","TX","WesTex Urgent Care, PLLC","Texas Mutual","Provider Load","Provider Load","","","","2025-04-25",""]
["Margaret Elizabeth O'Neal, FNP","1245067602","","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","In Process","Application Submitted","","","","2025-05-29","Enrollment inquiry submitted via email to Cigna Healthspring. MS"]
["Margaret Elizabeth O'Neal, FNP","1245067602","","TX","WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2025-04-25","Please see status updates under Alliance WC payor line. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","","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","","TX","WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2025-04-25","Submitted application via pswca.org. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2025-04-25","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2025-04-25","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","","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","","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","","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-04-30","Per updates@primehealthservices.com, the roster has been added effective 05/23/2023 which is the same effective date as the contract. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-04-30","Per updates@primehealthservices.com, the roster has been added effective 05/23/2023 which is the same effective date as the contract. Jen Videan"]
["Margaret Elizabeth O'Neal, FNP","1245067602","","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-04-29","","","2025-04-29","04/29/2025 CAQH Sweep-Completed-dvineyard"]
["Margaret Elizabeth O'Neal, FNP","1245067602","","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"]
["Sarai Avila Marks, APRN-NP","1619785656","","TX","Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2025-05-29","Pending Aetna approval. MS"]
["Jigar Maheshkumar Rathod, MD","1164721742","75-2656723","TX","Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2025-05-29","Provider is credentialed in TX, so just a demo form needed to be submitted to add this TIN. Request ID T47247676. MS"]
["James H Barnett, MD","1356484497","27-4061759","TX","Permian Cardiology Inc.","Liberty Mutual","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with WIN network in which this payor is included (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD","1356484497","27-4061759","TX","","Sedgwick","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with WIN network in which this payor is included (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD","1356484497","27-4061759","TX","","Omni PPO","Participating","Application Resubmitted","2010-12-29","1356484497","","2025-01-15","Application resubmitted via delegated roster. AS"]
["James H Barnett, MD","1356484497","27-4061759","TX","","First Health Coventry","Participating","Enrollment Complete","2023-02-01","3649611","","2023-03-08","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 02/01/2023. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3649611. Physical location is on file.  DCannon"]
["James H Barnett, MD","1356484497","27-4061759","TX","Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2011-01-27"," P01470034"," DS1746","2020-04-22","04/22/2020 -verified EFF info though payer site - Stacey Hudak"]
["James H Barnett, MD","1356484497","27-4061759","TX","Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","1998-07-23","1356484497","","2020-07-20","7/20/2020- Received a spreadsheet from the payer stating this provider is effective as of 7/23/1998. – Jerha Gayorgor"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","","Multiplan","Participating","Enrollment Complete","2011-07-15","1124009766","Individual contract","2020-07-06","07/06/2020 - Rec'd email from the payer stating: \n\"Thank you for contacting our Customer Service Department with Multiplan/PHCS. At this time we show that Pankaj Patel is currently participating with the Multiplan, PHCS, and BeechStreet networks. The provider became participating with Multiplan on 04/01/2007, PHCS on 07/01/2000, and Beech Street on 07/15/2011. The participation status is through an individual contract.\" - Stacey Hudak"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","Pankaj N. Patel, MD PA","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1124009766","","2020-09-16","09/16/2020 - Reviewed a spreadsheet rec'd from the payer stating this provider/service location has been affiliated with our PRIMED delegated roster - Stacey Hudak"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","Pankaj N. Patel, MD PA","United Health Care","Participating","Enrollment Complete","2020-03-01","1124009766","","2020-06-09","06/09/2020 - Rec'd email from the payer stating \"provider is part of a direct group contract\" - Stacey Hudak"]
["Pankaj J Patel, MD","1124009766","75-2784378","TX","Pankaj N. Patel, MD PA","Aetna","Participating","Add Info Submitted","2012-05-01","1124009766","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["John M McKenna, MD","1225170103","75-2656723","TX","","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","","CAQH","Participating","CAQH Reattested","2025-05-06","","","2025-05-06","05/06/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["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","","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["John M McKenna, MD","1225170103","75-2656723","TX","","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","","Boon Chapman","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","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","2024-02-28","Re-Cred has been completed. eff 1/2/2024. MS"]
["John M McKenna, MD","1225170103","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2021-12-01","1X1311","","2021-12-08","12/8/21 Provider approved 12/01/2021. PTAN 1X1311 Cbankston"]
["Michael J Dragun, MD","1679574099","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2024-08-05","","","2024-11-08","Received email from HP Delegation confirming participationg and effective date 8/5/2024. PA."]
["Michael J Dragun, MD","1679574099","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2024-10-01","6Y9793","0008AH","2024-10-08","Confirmed provider is linked. MS"]
["Mrunal C Patel, MD","1528000734","74-2348334","TX","Permian Gastroenterology PA","Medicaid","Participating","In House Enrollment","","080363701","Unknown","2020-10-23","10/23/2020 - Rec'd email from the clinic stating \"I spoke with Swapna Patel, the office manager for Dr. Mrunal and Dr. Govind Patel. \nYes, they participate in Medicaid but they will be taking care of it themselves.\n\nTheir TPI # is 0803637-01.\n\nShe doesn’t know the effective date because they’ve had it so long.\"  - Stacey Hudak"]
["Mrunal C Patel, MD","1528000734","74-2348334","TX","Permian Gastroenterology PA","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"]
["Willie Clyde Watson, III, MD","1659366433","75-2133441","TX","Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1659366433","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Willie Clyde Watson, III, MD","1659366433","75-2133441","TX","Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1659366433","","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"]
["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","Enrollment Complete","2021-01-07","","","2021-05-04","5/4/2021 Rcvd confirmation from Healthsmart <cgc.data@healthsmart.com> that provider is PAR and loaded under TIN and location effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2021-08-01","1103233","","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","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","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry portal. 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","","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment updates. MS"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","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"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-05-29","","","2024-07-09","Per providerdata@careworks.com request to add 3490 E Yukon Rd. has been completed. Jen Videan"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-05-31","Facility Enrollment. Providers services are billed through the facility, not an individual claim. MS"]
["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","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-29","","","2024-06-25","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"]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-01","","","2023-12-18","Welcome letter rcvd. Provider eff 12/01/2023. Jen Videan"]
["Lawrence A Wilson, MD","1518951342","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 9800227 DCannon"]
["Lawrence A Wilson, MD","1518951342","75-6000608","TX","City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete","2021-01-07","","","2021-06-04","6/4/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","1518951342","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"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","4705 Briarwood and 6950 Eastridge is effective 08/01/2022. Jen Videan"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","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","Payor Follow Up","2025-04-15","","","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."]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Delegated - Third Party","Payor Follow Up","2025-04-15","","","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."]
["Lawrence A Wilson, MD","1518951342","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"]
["Lawrence A Wilson, MD","1518951342","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"]
["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","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-12-20",""]
["Lawrence A Wilson, MD","1518951342","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"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-11-16","002438204","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 11/16/2021.  MPIN # 002438204.  DCannon"]
["Lawrence A Wilson, MD","1518951342","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-02-28","Provider is linked to this location 1/10/24. MS"]
["Lawrence A Wilson, MD","1518951342","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"]
["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","","","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","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-10-02","Per the Tricare portal, the provider is linked. MS"]
["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","75-2133441","TX","Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Re-Credentialing","2011-02-01","10120298","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Debbie P Reese, MD","1629074984","75-2133441","TX","Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2014-11-04","1629074984","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of  11/4/2014. – Elonah Grace B. Gelig"]
["Debbie P Reese, MD","1629074984","75-2133441","TX","Debbie P. Reese, MD PA","CAQH","Participating","CAQH Reattested","2025-04-15","","","2025-04-15","04/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Debbie P Reese, MD","1629074984","75-2182177","TX","Debbie P. Reese, MD PA","CAQH","Participating","CAQH Reattested","2025-04-15","","","2025-04-15","04/15/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Debbie P Reese, MD","1629074984","75-2182177","TX","Debbie P. Reese, MD PA","Multiplan","Participating","Enrollment Complete","2023-12-11","","","2024-06-04","6/3/2024 Spoke to Dominique call ref#10413020, location has been added to TIN as of 12/11/2023. FC"]
["Donald W Floyd, MD","1942216122","46-0950925","TX","","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"]
["Donald W Floyd, MD","1942216122","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","In Process","Application Submitted","","","","2025-04-04","Payer requested roster completion. This was completed for the group and emailed back to TXMA Contracting. MS"]
["Donald W Floyd, MD","1942216122","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2012-10-01","","","2024-09-09","Provider is linked to this location. MS"]
["Govind B Patel, MD","1073555249","74-2348334","TX","Permian Gastroenterology PA","United Health Care","Participating","Enrollment Complete","2020-03-01","1073555249","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Govind B Patel, MD","1073555249","74-2348334","TX","Permian Gastroenterology PA","USA PPO","Participating","Enrollment Complete","2002-11-15","1073555249","742348334","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["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","Permian Gastroenterology PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1073555249","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Govind B Patel, MD","1073555249","74-2348334","TX","Permian Gastroenterology PA","Scott&White (First Care)","Participating","Enrollment Complete","2016-02-29","1073555249","","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"]
["Govind B Patel, MD","1073555249","74-2348334","TX","Permian Gastroenterology PA","Superior","Participating","Enrollment Complete","2020-08-01","1073555249","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["John C Dean, MD","1013923291","46-3131679","TX","Midland Texas Orthopedic Group Inc","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["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","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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"]
["Srikanth R Deme, MD","1124103338","75-2949900","TX","","Aetna","Participating","Add Info Submitted","2023-10-01","1124103338","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["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","Boon Chapman","Participating","Enrollment Complete","2007-06-01","1811900657","","2020-10-05","Enrolled thru PHCS"]
["Shylesh R Ganta, MD","1811900657","20-8658501","TX","Shylesh Ganta, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Bhuvana Balasekaran, MD","1770564080","46-1602172","TX","Bhuvana Balasekaran, MD PA","Cigna","Participating","Enrollment Complete","2013-03-01","1770564080","","2020-04-21","04/21/2020--S/W Francis of Cigna @ 8008824462, provider NPI is on file for the provider and participating effective 03/01/13 under the group and TIN with direct contract. Physical location is on file. Provider ID#6815546. Call ref# FRANCIS0421.\n--copied note from spreadsheet-tisha rader"]
["Eric J Venegas, MD","1760485502","75-2930500","TX","Eric J. Venegas, MD, PA","Medicaid","Participating","Enrollment Complete","","144105701","","2020-08-26","8/26/2020 - the clinic only provider an TPI number. I was not given an effective date. - Stacey Hudak"]
["Eric J Venegas, MD","1760485502","75-2930500","TX","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","Rail Road Medicare","Participating","Enrollment Complete","2011-08-25","P01058301","CE1588","2020-03-25","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 08/25/2011 with provider number P01058301. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Kirit N Patel, MD","1295724698","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"]
["Kirit N Patel, MD","1295724698","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"]
["Kirit N Patel, MD","1295724698","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"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Application Resubmitted","2019-09-01","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","Aetna","Participating","Enrollment Complete","2018-08-14","1295724698","","2020-03-24","3/24/2020--S/W Erickof Aetna @ 18003531232, provider NPI# is on file for the provider and is participating effective 08/14/2018 under the group and TIN#. Physical location is on file. DIRECT CONTRACT--Call ref# 5192739438.\ntisha rader"]
["Kirit N Patel, MD","1295724698","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2012-03-01","01350302","","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"]
["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","Medicaid","Participating","Enrollment Complete","2023-03-26","121276305","079837301","2024-05-01","Rcvd Medicaid approval ltr. Provider effective 03/26/2023. Jen Videan"]
["Dario Beltran, MD","1912100850","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-13","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/13/2022.  DCannon"]
["P Douglas Cochran, MD","1316026396","20-0212181","TX","P. Douglas Cochran, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-05-22","5/22/2023 Rcvd email from Caprock that May roster has been processed and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["P Douglas Cochran, MD","1316026396","20-0212181","TX","P. Douglas Cochran, MD, PA","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-11-03","Received confirmation of update. W202310193478451 MS"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2016-02-09","","","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","Alliance WC","Participating","Enrollment Complete","2016-02-09","","","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","Scott&White (First Care)","Participating","Enrollment Complete","2020-07-01","","","2025-03-14","Received product roster from BSW 2.27.2025,  provider is listed PAR, linked to TIN/location, eff.  07/01/2020. PA."]
["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","Wellmed","Participating","Confirm Par Status","2023-01-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2023. PA"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2016-01-14","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 1/14/2016.  DCannon"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/05/2023. Jen Videan"]
["Terry L Beck, MD","1912991084","47-3465832","TX","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"]
["Terry L Beck, MD","1912991084","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."]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-11","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Jen Videan"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-05-29","","","2024-06-25","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"]
["Terry L Beck, MD","1912991084","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"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-01","4417046","","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","","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","Wellmed","Participating","Enrollment Complete","2023-01-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2023. PA"]
["Terry L Beck, MD","1912991084","47-3465832","TX","","Medicare","Participating","Enrollment Complete","2015-05-09","","","2024-04-30","Received confirmation the group enrollment record has been updated to show the Main St. location added eff 5/7/2024. The providers record is auto-updated to show the info as well. MS"]
["Terry L Beck, MD","1912991084","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-08","","","2025-05-08","05/08/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Terry L Beck, MD","1912991084","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-08-02","","","2023-09-26","Per providerdata@careworks.com all three locations added Effective 08/02/2023. Jen Videan"]
["Terry L Beck, MD","1912991084","47-3465832","tx","WesTex Urgent Care, PLLC","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","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","WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2015-05-09","","","2023-08-22","Confirmed provider is active at this location. MS"]
["Terry L Beck, MD","1912991084","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"]
["Terry L Beck, MD","1912991084","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"]
["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","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","","","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","","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"]
["Terry L Beck, MD","1912991084","47-3465832","tx","WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2023-01-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2023. PA"]
["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","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"]
["Terry L Beck, MD","1912991084","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."]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2004-10-01","1578557468","","2022-10-03","10/3/2022 Per TMHP web portal provider is PAR and linked to group effective 10/1/2004.  TPI# 1578557468.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","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","First Health Coventry","Participating","Enrollment Complete","2022-11-01","3637766","","2023-05-02","5/2/2023 Per confirm par status note -   Per rep, provider is participating with an effective date 11/01/2022 and link under the Group and TIN. Provider ID 3637766. As per Donna from there Credentialing Dept they don't have the provider's next recredentialing date then advised that their Network Team will inform the provider if the recredentialing Date is available. Service location is on file. Call ref#:610340.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2023-05-04","5/4/2023 Per email from UHC delegated roster from February has been processed.  Provider is PAR and linked to group TIN effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","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","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2024-12-03","Received confirmation via delegated roster from Emily Starr 11/22/2024. Provider participating 11/4/2024. AS"]
["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","Superior","Participating","Enrollment Complete","2022-11-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Jose G Delgado, MD","1578557468","75-2656723","TX","Premier Family Care, Inc","Multiplan","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","Caprock (CapStar)","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","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-07","","","2022-10-28","10/28/2022 Rcvd email from Scott & White that provider is PAR and linked to group TIN/locations effective 10/7/2022.  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","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","Omni PPO","Participating","Add Info Submitted","2022-09-12","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Vincent P Rascon, DPM","1346236924","91-1559006","TX","Vincent P. Rascon","TriCare Standard","Participating","Enrollment Complete","2020-11-01","","","2021-12-14","12/14/2021 Per note on 7/2/2021. Provider is certified as of 11/1/2020. Cbankston"]
["Vincent P Rascon, DPM","1346236924","91-1559006","TX","Vincent P. Rascon","Medicaid","Participating","Enrollment Complete","2020-12-16","018575301","","2020-12-18","12/18/2020 Recevied TMHP revalidation completion successful which is valid until 12/16/2025. KFrazier"]
["Vincent P Rascon, DPM","1346236924","91-1559006","TX","Vincent P. Rascon","Rail Road Medicare","Participating","Enrollment Complete","1997-10-01","480027409","N/A - no group link/PTAN","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","Andrews County Hospital District","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-27","Check Coventry portal for enrollment status, currently not enrolled. MS"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1730181389","","2020-07-01","07/01/2020 - rec'd email confirmation from the payer that this provider is EFF - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","Permian Physician Services","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","","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"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Texas Mutual","Participating","Enrollment Complete","2024-06-01","1730181389","","2024-06-11","Approval ltr rcvd. Effective date 06/01/2024. Jen Videan"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Alliance WC","Participating","Enrollment Complete","2023-11-03","","","2023-11-20","Rcvd approval ltr. Provider effective 11/03/2023. Jen Videan"]
["Rand E Waddingham, M.D.","1730181389","26-3789190","TX","Permian Physician Services","Travelers WC","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Aetna","Participating","Enrollment Complete","2009-04-01","4266535","","2020-07-10","07/10/2020 - moved to completed status per notes in Follow Up Complete  - Stacey Hudak"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","Andrews County Hospital District","Gallagher","Participating","Enrollment Complete","","","","2024-01-27","Confirmed provider is enrolled via the Integrated Network. MS"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","Andrews County Hospital District","Liberty Mutual","Participating","Enrollment Complete","2003-02-11","1730181389","751997880","2020-08-19","Confirmed provider is participating with WIN networks which includes this payor (list of networks attached). Kimberly Frazier"]
["Rand E Waddingham, M.D.","1730181389","75-1997880","TX","","Liberty Mutual","Participating","Enrollment Complete","2003-02-11","1730181389","751997880","2020-08-19","Confirmed provider is participating with WIN networks which includes this payor (list of networks attached). Kimberly Frazier"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","Rajanikant P. Pandya","Caprock (CapStar)","Participating","Add Info Submitted","2012-03-01","1316965403","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","","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","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"]
["Rajanikant P Pandya, MD","1316965403","56-2697415","TX","Rajanikant P. Pandya","Rail Road Medicare","Participating","In House Enrollment","","","","2020-10-26","10/26/2020 - This clinic performs their own medicare enrollment in house. They have not provided me with the proper information to check the status of this RR Medicare enrollment through the portal. Moved to IN HOUSE ENROLLMENT to remove from work list - Stacey Hudak"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","C Vallie CFNP Limited Partnership","HealthSmart PPO","Participating","Enrollment Complete","2021-02-08","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","C Vallie CFNP Limited Partnership","Tricare Prime","Panel Closed","Panel Closed","","","","2021-07-09","7/9/2021 The payor is no longer extending contracts to new groups at this time; however, required to check on-line for future openings of the panel. KFrazier"]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","75-2656723","TX","Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2024-09-01","","","2024-09-01","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Cheryl J. Vallie, APRN-FNP-BC","1417941410","20-4063608","TX","C Vallie CFNP Limited Partnership","CAQH","Participating","CAQH Reattested","2025-05-19","In-House Monthly Maintenance","","2025-05-19","05/19/2025 CAQH Reattested-updated providers phone#'s per email from Fernanda and added self insure COI and uploaded doc-dvineyard"]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","Joseph Damiani","Medicare","Participating","Enrollment Complete","2008-12-01","613616","613616 (provider and group in one enrollment)","2020-07-06","07/06/2020 - was able to obtain PECOS login and sign in to verify - Provider Medicare ID# 613616 EFF 12-1-2008 at service location of 2407 W Louisiana Ave - Stacey Hudak"]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","Joseph Damiani","Boon Chapman","Participating","Enrollment Complete","2016-01-01","","","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 1/1/2016.  DCannon"]
["Joseph M Damiani, MD","1093821274","39-9526391","TX","Joseph Damiani","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Anand C Reddy, MD","1780892760","26-3789190","TX","Permian Physician Services","Ambetter","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."]
["Anand C Reddy, MD","1780892760","81-3411343","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Anand C Reddy, MD","1780892760","26-3789190","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2024-01-25","","","2025-03-12","Received confirmation via email, provider participating as of 1/25/2024. FC"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","","Multiplan","Participating","Enrollment Complete","2020-04-01","1780892760","Permian Basin Kidney Center Inc","2020-05-05","05/05/2020 - Rec'd email from the payer stating \"The MultiPlan / PHCS Network Application for Anand Reddy and Asif Ansari is complete. Network participation became effective as of 4/1/2020 with MultiPlan and PHCS. The provider’s network participation is through Permian Basin Kidney Center Inc.\"  - Stacey Hudak"]
["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","","Galaxy Health","Participating","Enrollment Complete","2024-09-13","","","2025-02-03","Received  confirmation via email from Karen Avalos, provider participating as of 9/13/2024. FC"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","Permian Basin Kidney Center Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1780892760","","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"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","","Medicare","Participating","Enrollment Complete","2019-05-01","791813","791814","2020-05-01","05/01/2020 - Rec'd this information from the providers staff - Stacey Hudak"]
["Anand C Reddy, MD","1780892760","81-3411343","TX","Permian Basin Kidney Center Inc","Superior","Participating","Enrollment Complete","2020-10-01","1780892760","","2020-10-01","10/01/2020 - rec'd email from the payer stating this provider has been updated and made EFF off the roster - Stacey Hudak"]
["Melissa D Alworth","1942454525","75-2656723","TX","Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-08-05","","","2024-09-17","Received email confirmation roster was processed. Provider is par and linked to TIN/location, eff. 8/5/2024. PA."]
["Melissa D Alworth","1942454525","75-2656723","TX","Premier Family Care, Inc","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","1942454525","75-2656723","TX","Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2024-08-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 08/05/2024.  PA"]
["Melissa D Alworth","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","1942454525","75-2656723","TX","","Cigna","Participating","Enrollment Complete","2024-10-01","0323199","","2024-10-18","Received confirmation email. MS"]
["Melissa D Alworth","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","1942454525","75-2656723","TX","","Medicare","Participating","Enrollment Complete","2024-10-01","6Y9788","0008AH","2024-10-08","Confirmed provider is linked. MS"]
["Melissa D Alworth","1942454525","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2024-08-05","","","2024-10-07","Received confirmation via email from Jessica Bess, provider participating with Medicaid product effective 8/5/2024. FC"]
["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","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","4341928","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 4341928. KFrazier"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","","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","Enrollment Complete","2021-06-01","9672268","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 9672268  DCannon"]
["Chandan Mazumder, MD","1093928913","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"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2012-12-01","","","2020-09-14",""]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-09-01","","","2021-04-22","4/22/2021 Rcvd email from Kim Brechbiel <KJBrechbiel@aetna.com> that provider is particpating and linked to TIN/location effective 9/1/2020.  DCannon"]
["Chandan Mazumder, MD","1093928913","83-0358685","TX","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","","IMS","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["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.","Wellmed","Participating","Enrollment Complete","2023-05-08","","","2023-09-19","9/19/2023  Provider is PAR and linked to group/locations effective 5/8/2023.  DCannon"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","","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.","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"]
["Marcy L Askins, APRN-FNP-BC","1831441385","27-4061759","TX","Permian Cardiology Inc.","Caprock (CapStar)","Participating","Add Info Submitted","2023-05-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Khadijah A. Abdurrazaq, MD","1336304120","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"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-09-17","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 9/17/2020.  DCannon"]
["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","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"]
["Khadijah A. Abdurrazaq, MD","1336304120","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"]
["Khadijah A. Abdurrazaq, MD","1336304120","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"]
["Khadijah A. Abdurrazaq, MD","1336304120","83-0358685","TX","Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","815933","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 815933. KFrazier"]
["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 9/19/2013.  DCannon"]
["Maung K Hlaing, MD","1306167309","47-5554737","TX","Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-12-15","1306167309","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Maung K Hlaing, MD","1306167309","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1306167309","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF ath this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Maung K Hlaing, MD","1306167309","47-5554737","TX","Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1306167309","","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"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","Leo Villaroman, MD, PA","CAQH","Participating","CAQH Reattested","2025-05-08","","","2025-05-08","05/08/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","Leo Villaroman, MD, PA","United Health Care","Participating","Enrollment Complete","2023-01-09","","","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 1/9/2023.  MPIN# 003004855.  DCannon"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","Leo Villaroman, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-01-09","","","2023-01-20","1/20/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 1/9/2023.  DCannon"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","Tricare Prime","Participating","Enrollment Complete","2023-06-02","","","2024-01-25","Confirmed via the Tricare portal, the provider is Credentialed and In Network. MS"]
["Leo D Villaroman, MD","1073796330","26-3413331","TX","","Triwest VA","In Process","Payor Follow Up","","","","2025-05-12","Received response from Scarlett A stating provider is not enrolled. Resubmitted COI, DEA, and license for enrollment. PA."]
["Leela K Lella, MD","1306162557","27-4061759","TX","Permian Cardiology 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"]
["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","Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1306162557","","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"]
["Leela K Lella, MD","1306162557","27-4061759","TX","","USA PPO","Participating","Enrollment Complete","2018-10-15","1306162557","274061759","2020-08-21","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Leela K Lella, MD","1306162557","27-4061759","TX","Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2018-06-19","1306162557","","2020-02-12","02/12/2020 - Rec'd confirmation through payer portal stating : Provider:Leela Lella\nNetwork: MPI\nNetwork Participation effective:6/19/2018\nContract Source Group contract through DELEGATED PARTY: West Texas Physicians Alliance - Stacey Hudak"]
["Asif AK Ansari, MD","1528299872","26-3789190","TX","Permian Physician Services","Rail Road Medicare","Participating","Enrollment Complete","2024-06-20","","","2025-01-06","Provider is enrolled. MS"]
["Asif AK Ansari, MD","1528299872","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."]
["Asif AK Ansari, MD","1528299872","26-3789190","TX","","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."]
["Asif AK Ansari, MD","1528299872","26-3789190","TX","","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-12","Location is not Tricare certified, and the panel is closed to new locations. MS"]
["Asif AK Ansari, MD","1528299872","81-3411343","TX","","First Health Coventry","Participating","Enrollment Complete","2019-08-01","1528299872","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Asif AK Ansari, MD","1528299872","81-3411343","tx","Permian Basin Kidney Center Inc","Wellcare","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Asif AK Ansari, MD","1528299872","26-3789190","TX","","Multiplan","Participating","Enrollment Complete","2024-09-13","","","2024-11-08","Received confirmation via email from Jessica Bess, provider participating as of 9/13/2024. FC"]
["Asif AK Ansari, MD","1528299872","26-3789190","TX","","Medicare","Participating","Enrollment Complete","2024-06-20","6W9324","","2024-10-02","Per the MCR record, this provider is already linked and active with this TIN effective 6/20/2024. MS"]
["Asif AK Ansari, MD","1528299872","81-3411343","tx","","Superior","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Asif AK Ansari, MD","1528299872","26-3789190","TX","Permian Physician Services","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 AK Ansari, MD","1528299872","81-3411343","TX","","Rail Road Medicare","Participating","Enrollment Complete","2019-05-01","P02323200","DZ2789","2020-05-04","05/04/2020 - verified through portal and moved to completed status - Stacey Hudak"]
["Audrey N Mangwiro, MD","1346265162","47-5554737","TX","Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-12-14","","","2024-11-27","Provider is linked to this location. MS"]
["Audrey N Mangwiro, MD","1346265162","47-5554737","TX","Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2024-11-04","","","2025-02-03","Received  confirmation via email from Karen Avalos, provider participating as of 11/4/2024. FC"]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Alaaedin Alhomosh, MD","1063709913","75-2656723","TX","Premier Family Care, Inc","United Health Care","In Process","Payor Follow Up","","","","2025-05-27","Per UHC rep Charlie, a request to add provider to the group is pending. PR-9142871 submitted 05/22/25. PA."]
["Alaaedin Alhomosh, MD","1063709913","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"]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","","","","2025-04-23","Providers speciality has been updated to Critical Care (Intensivists) MS"]
["Alaaedin Alhomosh, MD","1063709913","47-5554737","TX","Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","2023-01-12","1.12.23 Called First Health @800-226-5116 and spoke with Stacey. Provider is participating at service location under Tax ID effective 12/1/22 with recredentialing every 3 years. Reference # 491471. ABoles"]
["Nancy N Asamoa, MD","1023135639","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2024-12-30","8849849","","2024-11-15","Provider confirmed. MS"]
["Nancy N Asamoa, MD","1023135639","47-5554737","TX","Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-09-15","469348ZV0W","519061","2024-11-06","Provider was already enrolled with TIN. MS"]
["Nancy N Asamoa, MD","1023135639","47-5554737","TX","Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2024-10-07","7278384","","2025-01-29","Received confirmation via roster (email) from Brandy Smith provider participating as of 10/7/2024. FC"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-09","1295109510","","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"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","361608801","079837301","2020-08-10","08/10/2020 -  Rec'd notification that the recred has been approved for this provider - Stacey Hudak"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-22","Per TMHP request has been closed and provider is enrolled. 400 Rosalind Redfern Grover Pkwy STE 200, Midland, TX, 79701-5852 and 600 Washington Ln, Odessa, TX, 79761-7011 effective 03/14/2023. Jen Videan"]
["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","Medicare","Participating","Enrollment Complete","2016-02-15","483780YPVD","0008AH","2020-03-25","03/25/2020 - Signed into providers PECOS and verified this provider is linked to our group via employer - Stacey Hudak"]
["Samuel L Baumguardner, PA","1295109510","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1295109510","","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"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2025-04-11","12803191","","2025-04-11","04/11/2025 CAQH Reattested-updated TX lic exp 5.31.27 and uploaded doc-dvineyard"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Jessie J Dickens, MD","1215254156","46-3131679","TX","Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Confirm Par Status","2019-08-01","1215254156","","2025-02-07","Received email from payor, confirming provider is par, linked to TIN & location, with eff. date of 08/01/2019. PA."]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2023-10-25","4158006","","2023-11-01","Received confirmation email. Provider is effective 10/25/23. MS"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-05","","","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 7/5/2023.  DCannon"]
["Christopher Ryan Vela, PA","1366728909","27-4061759","TX","Permian Cardiology Inc.","Caprock (CapStar)","Participating","Application Resubmitted","2023-02-01","","","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","","HealthSmart PPO","Participating","Enrollment Complete","2018-08-10","1770883191","","2020-06-05","06/05/2020 - rec'd email from the payer stating provider is EFF - stacey Hudak"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","1770883191","","2024-06-20","Revalidation approval letter rcvd. Jen Videan"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2015-07-01","1770883191","","2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF as of 7-1-2015 under a DIRECT CONTRACT. No reval information was provided - Stacey Hudak"]
["Haritha Bellam, MD","1770883191","75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2020-01-01","1770883191","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","384181902","079837301","2020-01-29","01/29/2020 - moved to completed status after confirming provider is linked in payer portal. Provider is participating with the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2018-07-24","1275044422","","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 J Hester, APRN-AGACNP","1275044422","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1275044422","","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"]
["Michael J Hester, APRN-AGACNP","1275044422","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-04-01","662202","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","Cigna","Participating","Enrollment Complete","2021-03-31","5803477","","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 \t\n5803477. KFrazier"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2005-07-01","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Eliseo Rivera, MD","1013990761","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."]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2017-01-01","1013990761","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["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","Superior","Participating","Enrollment Complete","2020-09-01","","","2020-09-02","09/02/2020 - Rec'd email confirmation that this service location has been added to the provider profile - Stacey Hudak"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-10-03","","","2022-02-24","2/24/2022 Received roster from Multiplan confirming participation of providers with TIN /locations effective 10/3/2017.  DCannon"]
["Eliseo Rivera, MD","1013990761","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"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1013990761","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Eliseo Rivera, MD","1013990761","83-0358685","TX","Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-04-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 4/3/2020.  DCannon"]
["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","Cigna","Participating","Enrollment Complete","2021-05-06","8228233","","2021-05-07","5/7/2021 Received email from discovercigna@information.cigna.com confirming provider has been approved effective 5/6/2021 with assigned provider ID number 8228233. KFrazier"]
["Karen Ward, APRN-NP, RNFA","1790831493","47-5554737","TX","Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2021-05-01","","","2021-05-04","5/4/2021 Rcvd email from Superior confirming that the providers are PAR and loaded under TIN/locations effective 5/1/2021.  DCannon"]
["Karen Ward, APRN-NP, RNFA","1790831493","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2020-12-19","Q00055190","DW7662","2021-04-12","4/12/2021 Received assigned RR PTAN Q00055190, effective 12/19/2020 under group RR PTAN DW7662. KFrazier"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Medicare","In Process","Pending Info/Document","2013-10-01","322577YN4B","","2025-03-04","pending surrogacy. MS"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Liberty Mutual","Participating","Enrollment Complete","2018-10-01","","","2021-01-25","1/25/2021 - Rcvd email from payer confirming participating under tax ID and at location effectice 10/1/2018.  DCannon"]
["Stephen P Dodd, PA","1598976011","46-0950925","TX","Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","1598976011","","2020-08-31","08/31/2020 - moved to completed status afer reviewing follow up complete note - under PRIMED - Stacey Hudak"]
["Stephen P Dodd, PA","1598976011","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."]
["Nanette R Paredes, PA","1437175163","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Application Resubmitted","2018-10-03","1437175163","","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","Humana","Participating","Enrollment Complete","2018-10-03","1437175163","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Frank O McGehee, IV, MD","1134151756","27-0950535","TX","McGehee Medical, PA","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","McGehee Medical, PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1134151756","","2020-06-04","06/04/2020 - moved to completed status after getting email from payer that this provider is EFF - 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","Premila Johnson, MD, LP","Caprock (CapStar)","Participating","Enrollment Complete","2012-09-01","1184727562","","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"]
["Premila L. S. Johnson, MD","1184727562","90-0858471","TX","Premila Johnson, MD, LP","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","","Aetna","Participating","Application Resubmitted","2024-02-01","","","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","47-3465832","tx","WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2020-06-02","002854139","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 06/02/2020. PA."]
["Johnny L Flitton, PA","1437356730","84-2617748","TX","Midland Medicine PA","Omni PPO","Participating","Enrollment Complete","2024-03-08","","","2024-08-08","8/8/2024 Spoke to Kodi, provider patricipating as of 3/8/2024, listed as physician assistant family practice. FC"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2015-08-28","","","2024-07-02","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 08/28/2015. PA"]
["Johnny L Flitton, PA","1437356730","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"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-02","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location approved eff 10/9/23. MS"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location approved eff 10/9/23. MS"]
["Johnny L Flitton, PA","1437356730","47-3465832","tx","WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-06","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/6/2023.  DCannon"]
["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","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."]
["Johnny L Flitton, PA","1437356730","84-2617748","TX","Midland Medicine PA","Aetna","Participating","Enrollment Complete","2024-02-05","","","2024-07-18","Spoke to Kim B call ref#6198188640, provider participating as of 2/5/2024 as PCP. FC"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Omni PPO","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","","","","2025-02-12","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["Johnny L Flitton, PA","1437356730","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"]
["Johnny L Flitton, PA","1437356730","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."]
["Johnny L Flitton, PA","1437356730","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"]
["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","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"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-08-01","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 08/01/2023. Jen Videan"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","IMS","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","Multiplan","Opt Out","Re-Credentialing","2020-04-03","","","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","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."]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-11-26","","","2025-02-20","Confirmed enrollment via Tricare Portal. MS"]
["Johnny L Flitton, PA","1437356730","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"]
["Johnny L Flitton, PA","1437356730","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"]
["Johnny L Flitton, PA","1437356730","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-08","12235261","","2025-05-08","05/08/2025 CAQH Reattested-added symplr email and Cred Cont again bc it had been removed-dvineyard"]
["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","Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing","2020-08-01","1912068446","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","CAQH","Active","CAQH Reattested","2025-05-29","13752595","","2025-05-29","05/29/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","Sedgwick","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","","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is participating under group Tax ID effective 12/1/2020 and assigned PIN number 9631791. Kimberly Frazier"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","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"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","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"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1760501720","","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"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2008-05-13","1760501720","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2008-01-01","8K8025","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Gerardo M Catalasan, MD","1760501720","75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2023-08-21","","","2025-02-05","Approval ltr rcvd. Effective 08/21/2023. Jen Videan"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2015-04-29","01448885","","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"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2008-11-01","P00716501","","","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2008 with provider number P00716501. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2009-07-01","1093937948","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 7-1-2009. Provider is networked with Beechstreet. - Stacey Hudak"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2010-04-16","1093937948","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2009-03-24","194906703","079837301","2020-03-13","03/13/2020 - Clinic forwarded Medicaid TMHP approval letter showing where the provider was linked to the group - Stacey Hudak"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-10-22","","","2020-11-17","11/17/2020 - Checked the Humana-Military website provider credentialing is completed effective 10/22/20.  DCannon"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2008-11-01","P00716501","","2020-03-30","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2008 with provider number P00716501. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-02-26","6493392","","2021-11-15","11/15/2021 Per f/u note S/W Steven of Cigna @ 800-882-4462. NPI# for the provider is on file  shows LINKED and  Par under the group and TIN#,  effective 2/26/2020 , the physical location is on file and the Provider ID is 6493392.   DCannon"]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1093937948","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - stacey hudak"]
["Nikolay A Azarov, MD","1093937948","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."]
["Nikolay A Azarov, MD","1093937948","75-2656723","TX","","Liberty Mutual","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","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"]
["Jeffrey Limbacher, PA-C","1376723361","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Texas Mutual","Participating","Enrollment Complete","2017-09-01","","","2025-01-14","Please see status updates under group record payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","Humana","Participating","Enrollment Complete","2020-01-01","1376723361","","2020-07-17","7/17/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","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","","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2025-02-12","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","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","47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-10-02","Per the Tricare portal, the provider is linked. MS"]
["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","","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","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","75-2656723","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1376723361","","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"]
["Jeffrey Limbacher, PA-C","1376723361","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"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11","1376723361","","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"]
["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","75-2656723","TX","Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2025-05-08","13780299","","2025-05-08","05/08/2025 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","2025-05-08","13780299","","2025-05-08","05/08/2025 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","2025-05-08","13780299","","2025-05-08","05/08/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","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."]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-01-03","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 1/3/2022.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-11-27","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","","Humana","Participating","Enrollment Complete","2018-02-22","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 02/22/2018. PA"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-26","","","2024-03-06","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/26/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-26","","","2024-03-06","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/26/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","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","","","2023-09-26","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","","","2023-10-26","Eastridge location confirmed eff 10/9/23. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Sedgwick","Participating","Enrollment Complete","2024-05-29","","","2024-07-09","Per providerdata@careworks.com request to add 3490 E Yukon Rd. has been completed. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-18","Received confirmation of enrollment. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","TriCare Standard","Participating","Enrollment Complete","2024-11-26","","","2025-02-20","Confirmed enrollment via Tricare Portal. MS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","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","","Alliance WC","Participating","Enrollment Complete","2024-05-29","","","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","United Health Care","Participating","Enrollment Complete","2020-08-22","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 08/22/2020. PA"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Jeffrey Limbacher, PA-C","1376723361","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"]
["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","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","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","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","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-01-06","Per updates@primehealthservices.com, provider has been added. Effective 05/23/2023. Jen Videan"]
["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","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","","Medicare","Participating","Enrollment Complete","2024-12-03","","","2025-01-03","Provider is active and linked to the group record. MS"]
["Jeffrey Limbacher, PA-C","1376723361","75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR for Ambetter product and linked to group delegation roster effective 4/1/2022."]
["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","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Cigna","Participating","Enrollment Complete","2024-12-02","8867748","","2024-12-20","Received confirmation email. MS"]
["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","2024-02-23","","","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","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","Sedgwick","Participating","Enrollment Complete","","","","2025-02-09","Per providerdata@careworks.com, address has been added. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","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","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","","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"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2017-11-30","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 11/30/2017.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","tx","WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-10-02","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C","1376723361","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Sapna Chilka, MD","1790972610","20-8658501","TX","Shylesh Ganta, MD, PA","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"]
["Sapna Chilka, MD","1790972610","20-8658501","TX","Shylesh Ganta, MD, PA","USA PPO","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Ajay K Vaikuntam, MD","1447415476","47-5554737","TX","Midland Inpatient Medical Association","Omni PPO","Participating","Re-Credentialing","2019-09-01","1447415476","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Ajay K Vaikuntam, MD","1447415476","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Re-Credentialing","2020-04-15","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Ajay K Vaikuntam, MD","1447415476","47-5554737","TX","Midland Inpatient Medical Association","Boon Chapman","Participating","Re-Credentialing","2020-04-15","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Wayne L Sager, MD","1225182314","75-2133441","TX","Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete","2009-08-28","350398","","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"]
["Tareq Hulali, MD","1194813709","90-0956632","TX","Tareq Hulali, MD LLLP","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"]
["Tareq Hulali, MD","1194813709","90-0956632","TX","Tareq Hulali, MD LLLP","CAQH","Participating","CAQH Reattested","2025-06-09","12064910","","2025-06-09","06/09/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Shailesh Jain, MD","1215922802","75-2656723","TX","Premier Family Care, Inc","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","Cigna","Participating","Enrollment Complete","2024-03-20","60308","","2024-03-22","03.22.2024 WR: Called Cigna@ 1-800-882-4462 to obtain PNP/FU status for the provider and spoke to PaulaM. Per rep, Provider is in network with Cigna for the state of TX and linked to the group and TIN# effective 03/20/2024. Next recredentialing date is on 03/20/2027. PIN: 0998740. Servicing location is on file. Payer# 60308. Call ref# PaulaM03242024."]
["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","Premier Family Care, Inc","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","Omni PPO","Participating","Enrollment Complete","2019-09-01","1376556019","","2020-07-27","IMS completed"]
["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","Medicare","Participating","Enrollment Complete","2011-09-06","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","Galaxy Health","Participating","Enrollment Complete","2011-09-01","1376556019","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Staton Awtrey, MD","1376556019","75-2656723","TX","Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2011-09-01","","","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"]
["Juan C Gil, MD","1558392779","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-04","1558392779","","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"]
["Juan C Gil, MD","1558392779","75-2656723","TX","Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","187586602","079837301","2024-07-26","Approval ltr rcvd for 2402 W Wall St. Effective 05/29/2023. Jen Videan"]
["Juan C Gil, MD","1558392779","75-2656723","TX","Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2010-08-01","1558392779","","2020-02-20","02/20/2020 - This provider is EFF 8-1-2010 and linked to our group TIN, but the provider is linked to a DELEGATED Group. Cigna could not determine what delegated entity - Stacey Hudak"]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","","Scott&White (First Care)","Participating","Add Info Submitted","2020-09-28","","","2025-03-18","Submitted TPI to payor via delegated roster. PA."]
["Rebecca A Sanchez, PA","1174846364","46-3131679","TX","Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2020-03-20","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Liberty Mutual WC and linked to TIN/locations effective 3/20/2020.  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","Omni PPO","Participating","Enrollment Complete","2019-09-01","1174846364","","2020-07-27","IMS complete"]
["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","","Aetna","Participating","Add Info Submitted","2015-12-01","9826163","","2025-02-14","Submitted name change via delegated roser on 2/14/2025. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","First Health Coventry","Participating","Add Info Submitted","2010-08-01","1945548","","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","HealthSmart PPO","Participating","Add Info Submitted","2021-08-02","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Amerigroup","Participating","Add Info Submitted","2020-04-15","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Medicaid","Participating","Enrollment Complete","2010-07-25","284181901","","2023-09-18",""]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2020-07-02","1881711778","","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 7/2/2020.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2021-08-13","1881711778","","2021-09-15","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1881711778","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","USA PPO","Participating","Enrollment Complete","2021-08-02","1142937","","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 8/2/2021.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1881711778","","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"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2021-08-02","1881711778","","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 8/2/2021.  DCannon"]
["Michael P Wolbert, MD","1881711778","75-2781652","TX","West Texas Allergy, PA","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","Medicaid","Participating","Enrollment Complete","2010-07-25","1881711778","","2023-12-14","Michael Wolbert NPI is a performing provider of the group for any location of the group. Jen Videan"]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","Ayodele O Olowookere MD, PA","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."]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","Ayodele O Olowookere MD, PA","USA PPO","Participating","Enrollment Complete","2014-06-02","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Ayodele Olowookere, MD","1124350442","49-4110931","TX","Ayodele O Olowookere MD, PA","Multiplan","Participating","Re-Credentialing","2016-05-16","1124350442","","2024-05-15","5/15/2024- Submitted recred status via delegated monthly roster. FC."]
["Rosanna Y Catalasan, MD","1487837712","75-2656723","TX","Premier Family Care, Inc","IMS","Participating","Re-Credentialing","2010-02-26","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","TriCare Standard","Participating","Enrollment Complete","2018-11-30","1487837712","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Aaron B Stike, MD","1366652315","75-2656723","TX","Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2024-11-01","","","2024-11-20","REF# 173759248. Provider is linked to this location and active under the TIN. MS"]
["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","PPHP","Participating","Enrollment Complete","2024-08-05","","","2024-08-30","Received email confirmation provider is PAR and linked to TIN/location, eff. 08/05/2024. PA."]
["Viktor Miro, MD","1073856019","47-5554737","TX","Midland Inpatient Medical Association","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"]
["Viktor Miro, MD","1073856019","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"]
["Viktor Miro, MD","1073856019","47-5554737","TX","Midland Inpatient Medical Association","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"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","","Aetna","Participating","Enrollment Complete","2024-05-22","602568","","2024-08-22","Spoke to Jessica call ref#6200938288 provider participating as of 5/22/2024 as a SPEC. I will email Brandy Smith to have his designation role corrected to PCP. FC"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","Delight Pediatrics","Humana","Participating","Enrollment Complete","2024-05-01","2618646","","2024-08-19","Per Humana rep, Rachel D, 1-800-448-6262, ref# 2000402330573, provider is participating and linked to TIN & location, eff. 05/01/2024. PA"]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","Delight Pediatrics","Ambetter","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","","TriCare Standard","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","","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2025-03-04","Per Triwest VA rep Scarlett A, pediatric specialty not accepted. PA."]
["Mohammed H Aljarwi, MD","1013320050","92-0675116","TX","Delight Pediatrics","BCBSTX","Participating","Enrollment Complete","2024-09-05","","","2024-09-05","Received email confirmation provider is PAR and linked to TIN/location, eff. 9/5/2024. Provider is participating in the following LOB's: Blue Choice PPO: 09/05/2024 \nBlue Essentials HMO: 09/05/2024  \nHealth Select: 09/05/2024 . PA"]
["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"]
["Michael T Caglia, MD","1568789550","85-3162122","TX","Basin Dermatology","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-06-04","6/4/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective 6/1/2021.  DCannon"]
["Joan S R Petalcorin, MD","1619008141","75-2656723","TX","Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-10-05","1619008141","","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"]
["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","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."]
["Alim M Ladha, MD","1093935975","45-3020135","TX","Alim M. Ladha, MD","Boon Chapman","Enrollment Stopped","Enrollment Stopped","","","","2023-10-16","10/16/2023 Provider is not enrolled in Multiplan, therefore, provider is not enrolled in Boon Chapman.  DCannon"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-02-23",""]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","CAQH","Participating","CAQH Reattested","2025-05-28","","","2025-05-28","05/28/2025 CAQH Reattested-all information is correct and up to date-dvineyard"]
["Leela Sharath Pillarisetty, MD","1235484114","86-3825791","TX","West Texas Ob/Gyn","HealthSmart PPO","Participating","Application Resubmitted","2022-01-10","","","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","Medicaid","Participating","Enrollment Complete","","","","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","Humana","Participating","Enrollment Complete","2022-01-10","","","2022-06-19","6/19/2022 Per email received from V. Thomas at Humana provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Leela 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","Midland Inpatient Medical Association","Medicaid","In Process","Application Submitted","2016-09-16","","","2025-05-22","Re-enrollment application submitted via TMHP. Request ID: 20715417. Your application has been submitted and is now under review. Your request number is: 20715417. Jen Videan"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","Midland Inpatient Medical Association","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"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","","PPHP","Participating","Enrollment Complete","2024-09-09","","","2024-10-04","Received email confirmation Sept roster is processed. Provider is participating, linked to TIN and location, effective 9/9/2024. PA."]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","","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","","Tricare Prime","Panel Closed","Panel Closed","","","","2024-08-12","Location is not Tricare credentialed, and the panel is closed to new enrollment. MS"]
["Anju B Varanasi, MD","1407070162","47-5554737","TX","Midland Inpatient Medical Association","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"]
["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","","","2024-08-30","Approval Ltr rcvd. Effective 09/01/2024. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-11-26","","","2025-02-20","Confirmed enrollment via Tricare Portal. MS"]
["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","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","In Process","Application Resubmitted","2024-06-01","6S4368","423838","2025-04-21","Application resubmitted and AO Signature Page uploaded. App was sent to the provider for signature. T042120250003630 MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Medicare","In Process","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","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["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","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."]
["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","","","2024-10-08","Approval ltr rcvd, Effective 09/18/2024. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2024-10-08","Approval ltr rcvd, Effective 09/18/2024. Jen Videan"]
["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","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","Pending Contracting","","","","2024-06-10","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Henry B Sirengo, RN, FNP-BC","1285175927","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-08-16","","","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","Alliance WC","Participating","Enrollment Complete","2024-08-16","","","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","United Health Care","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","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","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2025-01-06","Per updates@primehealthservices.com, provider has been added. Effective 05/23/2023. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC","1285175927","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"]
["Henry B Sirengo, RN, FNP-BC","1285175927","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"]
["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 Stopped","2024-06-10","","","2024-10-02","Longview location was termed 5/2024"]
["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","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","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/locations, eff. 08/01/2024. 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","Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1053601344","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019 - Jesriel Segovia"]
["Tiffany D Cossey, MD","1053601344","75-2656723","TX","","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","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","Boon Chapman","Participating","Enrollment Complete","2019-04-04","","","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 4/4/2019.  DCannon"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","","IMS","Participating","Enrollment Complete","2018-02-28","1972816189","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2017-09-01"," P02260538","DS1746","2020-10-09","10/9/2020 - double checked the PTAN and found it was reveresed in the payer line. Found working/effective RRMCRPTAN and updated payer line - Stacey Hudak"]
["Evbu O Enakpene, MD","1972816189","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"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","","Cigna","Participating","Enrollment Complete","2019-06-04","1972816189","","2020-08-26","08/26/2020 - moved to completed status after reviewing followup complete note - Stacey Hudak"]
["Evbu O Enakpene, MD","1972816189","27-4061759","TX","","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","47-5554737","TX","Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2025-04-24","","","","04/24/2025 CAQH Reattested-Per Priscilla provider has decided not term with Midland Impatient Medical-restored Prac Loc 400 Rosalind Redfern Grover Pkwy.-dvineyard"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2025-03-01","0040519489","","2025-03-28","Provider is par, linked to TIN/location, eff. 3/1/2025, per email from Wellmed. PA."]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-11-01","6C4060","0008AH","2023-11-01","Received enrollment confirmation eff 11/1/2023. MS"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-09","","","2023-11-03","11/3/2023 Per email received from Scott & White provider is PAR and linked to group effective 11/9/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","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","84-2617748","TX","Midland Medicine PA","Boon Chapman","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","Midland Medicine PA","First Health Coventry","Participating","Enrollment Complete","2022-06-01","3165776","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2022.  PID# 3165776 DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","75-2656723","TX","Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD","1760860720","84-2617748","TX","","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","HealthSmart PPO","Participating","Enrollment Complete","2016-09-15","1255614970","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Amber J White, PA","1255614970","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-08-02","P01784546","DW7662","2020-10-20","10/20/2020 - found effective info with the payer and updated payer line  -  Stacey Hudak"]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-07-08","6703681","","2021-07-09","7/9/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 7/8/2021 with assigned provider ID 6703681. KFrazier"]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","","Cigna","Participating","Terminated","2016-12-20","6703681","","2021-05-24","5/24/2021 Provider was loaded under delegation with WTPA; however, client terminated relationship and provider was termed effective 3/31/2021. Confirmed provider is not currently credentialed outside of delegation and requires full credentialing. Kfrazier"]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-08-21","","","2021-04-07","4/7/2021 Rcvd roster from Mary Rodriguez 4/5/2021 listing provider as participating.  DCannon"]
["Luis F Hernandez, DO","1447412895","47-5554737","TX","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"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","HealthSmart PPO","Participating","Application Resubmitted","2014-09-23","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","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","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","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 11/1/2021. PA."]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","USA PPO","Participating","Enrollment Complete","2016-03-31","1210786","","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"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","Permian Digestive Disease Center PA","Medicaid","Participating","In House Enrollment","2016-01-09","","","2021-08-06","8/6/2021 Group processes enrollment In-House; however, confirmed provider is participating with group effective 9/1/2016. KFrazier"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","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","","First Health Coventry","Participating","Enrollment Complete","2016-07-01","1912442","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 7/1/2016 PID # 1912442\ntisha rader"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","First Health Coventry","Participating","Application Resubmitted","2024-02-13","","","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","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-30","1/30/2024 Per UHC portal provider load in Wellmed is still pending.  Will check back in a few days.  DCannon"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","Permian Digestive Disease Center PA","Aetna","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","Permian Digestive Disease Center PA","Rail Road Medicare","Participating","Enrollment Complete","2016-01-09","P01708900","DW5495","2024-03-06","Provider is enrolled. MS"]
["Indira Donepudi, MD","1447406137","81-1031742","TX","","Medicare","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation from the group enrollment that all information has been updated. There is no individual enrollment needed for the provider. MS"]
["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","","","2024-03-08","Rcvd approval letter. Provider effective 03/01/2024. Jen Videan"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-07-26","","","2024-10-14","Per Dee Dee Johnson at Texas Mutual site visit completed on 07/26/2024. Jen Videan"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["John Petersen, MD","1972506442","47-3465832","TX","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","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","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","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","Sedgwick","Participating","Enrollment Complete","2024-05-21","","","","Approval ltr rcvd. Effective 05/21/2024. 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","Aetna","Participating","Enrollment Complete","2024-02-05","","","2024-10-31","Received confirmation via delegated roster provider participating as of 2/5/2024. FC"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-03-01","","","2024-06-26","Spoke to Rick P call ref# 1106851 he indicated provider is participating as of 3/1/2024 with all 5 locations. 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","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"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-02-05","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 02/05/2024. PA."]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-21","1972506442","","2024-05-22","Approval ltr rcvd. Effective 05/21/2024. Jen Videan"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-21","1972506442","","2024-05-22","Approval ltr rcvd. Effective 05/21/2024. Jen Videan"]
["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","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","Liberty Mutual","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","In Process","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","Medicare","In Process","Application Resubmitted","2024-02-01","6H8501","","2025-04-21","Application resubmitted and AO Signature Page uploaded. App was sent to the provider for signature. T042120250003760 MS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-29","","","2024-08-06","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["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","Humana","Participating","Enrollment Complete","2024-02-05","","","2025-03-25","Received WTUC roster 3.19.2025 from Humana via secure message; provider is listed PAR, linked to TIN/location, eff. 02/05/2024. PA."]
["John Petersen, MD","1972506442","47-3465832","tx","WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD","1972506442","47-3465832","TX","WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD","1972506442","47-3465832","tx","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","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","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","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","Multiplan","Participating","Add Info Submitted","2020-04-03","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","","Aetna","Participating","Enrollment Complete","2020-08-01","","","2024-08-27","Provider participating as of 8/1/2020, listed as PCP, received via roster from Brandy Smith. FC"]
["Tiffany B Hansen, APRN-FNP-BC","1750794749","20-8658501","TX","","Aetna","Participating","Add Info Submitted","2020-08-01","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-05-15","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/15/2020.   DCannon"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-05-15","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/15/2020.   DCannon"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-08-24","P01732063","DW7662","2020-10-09","10/9/2020 - Was able to confirm RR Medicare enrollment thorugh payer site - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD","1710180666","47-5554737","TX","Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1710180666","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["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","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 07/18/2019.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-02-12","","","2022-06-01","6/1/2022 Per Galaxy Health provider is PAR and linked to group TIN/location effective 2/12/2020.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","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","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Irina Remsburg, MD","1639439185","83-0358685","TX","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","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","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","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-03-01","3/1/2021 Rcvd confirmation that provider is participating with Healthsmart PPO effective 1/7/2021.  DCannon"]
["Ali R Khan, MD","1760714380","47-5554737","TX","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."]
["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","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","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","Corvel Healthcare Corp.","Participating","Enrollment Complete","2025-02-12","","","2025-02-12","Approval ltr rcvd. effective 02/12/2025. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2025-01-24","","","2025-02-03","Welcome ltr rcvd. Effective 01/24/2025. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2025-02-19","","","2025-02-21","Approval ltr rcvd. Effective 02/19/2025. 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","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","In Process","Application Resubmitted","","","","2025-01-15","Submitted via Liberty Mutual application site. AS"]
["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","TriCare Standard","Participating","Enrollment Complete","2024-10-24","","","2024-11-26","Provider is linked to Briarwood location eff 10/24/24. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-10-24","","","2024-11-26","Provider is linked to Briarwood location eff 10/24/24. 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","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","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","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","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","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","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"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-11-27","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","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","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","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","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","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","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","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","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","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","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["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","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-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","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-dvineyard"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2025-05-13","","","2025-05-13","05/13/2025 CAQH reattested per email-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","","","","2025-02-12","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["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","Pending Other Enrollment","Pending Other Enrollment","","","","2025-02-20","Pending initial enrollment into Sedgwick...in process. Jen Videan"]
["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","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. PA."]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2025-05-27","Sent follow up email to LaNetrice requesting status. 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","","","2025-01-14","Please see status updates under group record payor line. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","","","","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","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","tx","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA","1437650934","47-3465832","TX","WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["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","2025-05-13","","","2025-05-13","05/13/2025 CAQH Reattested per email-dvineyard"]
["Saranya Rajasekar, MD","1871028365","75-2656723","TX","","CAQH","Participating","CAQH Reattested","2025-05-13","","","2025-05-13","05/13/2025 CAQH Reattested per email-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","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","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","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","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","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","2025-05-29","13885700","","2025-05-29","05/29/2025 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","Provider Load","CAQH Reattested","2025-04-15","","","2025-04-15","04/15/2025 CAQH Reattested-all information is correct and up to date-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","2021-03-01","3/1/2021 Received nofication TMHP revalidation has been completed successfully and provider is due for revalidation 2/25/2026. KFrazier"]
["Jeremiah L Stewart, APRN-FNP-BC","1649713595","47-5554737","TX","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","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","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","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"]