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["Providers Full Name","Providers NPI","Tax ID#","State","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indv ID#","Grp ID#","Note Date","Notes","Symplr Rep","Enroll Type","Practice Address","Practice Address 2","Practice City","Practice Zip Code"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2018-08-30","1790767119","","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"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-09-07","9/7/2023 Per email rcvd from Scott & White delegated roster for June has bee completed.  Provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2018-10-01","1790767119","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","ME","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","","","2021-08-25","8/25/2021 Received an email from PDMCOGZ@cigna.com confirming provider is now participating under group Tax ID and location effective 3/31/2021 with assigned provider ID 6670877. KFrazier"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2018-09-01","1790767119","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 9-1-2018 with a DIRECT CONTRACT. The proper service location is in file - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2023-08-25","Confirmed via website the provider is listed on directory. Will need to call rep for effective date. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","In Process","Application Submitted","","","","2023-09-06","Submitted email request to add new location to Intake email. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2018-07-14","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-07-19","","","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 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2023-09-01","9/1/2023 Sent follow-up email to Marcus Wester at Humana to check status of June monthly delegated roster submission.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-07-12","","","2023-08-14","08.01.2023 S/W Alvin of Aetna @ 800-353-1232. Per rep, provider is showing participating with Aetna under the state of Texas and link under the Group and TIN with an Effective date 07/01/2022. Provider ID 6312366. Service address is on file. Call ref#:6157637573. - Danico Gabriel Melendres"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2018-07-10","","","2023-09-05","9/5/2023 Per email response from UHC delegated roster for June has been completed.  Provider is PAR and linked to group TIN/location effective 7/10/2018.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","In Process","Application Submitted","","","","2023-08-23","F/U - Provider is now Tricare certified, but not linked to this location. I have submitted the request to have the provider linked. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-04","","","2023-08-21","Per TMHP welcome letter provider effective 08/04/2022. Jen Videan"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2018-08-29","1790767119","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - rec'd confirmation from Multiplan/Texas True Choice that this is correct - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2018-08-01","1046218","","2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 8/1/2018 PID # 1046218\ntisha rader"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","386238501","079837301","2020-01-29","01/29/2020 - Found provider PAR through payer portal. This provider is linked to the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1790767119","","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"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2018-07-10","","","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 7/10/2018.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-07-19","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-07-01","679507","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-07-21",""]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19","","","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 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-08-01","1790767119","","2020-02-12","02/12/2020 - this provider has been confirmed to be effective through the payer portal. EFF 8-1-2018 THROUGH WEST TEXAS PHYSICIANS ALLIANCE DELEGATED PARTY - networked to MPI. - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-07-14","","","2020-11-03","11/3/2020 Upon review of the self-service portal provider reflects as 'complete'. Kimberly Frazier"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-08-28","1790767119","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","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."]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-07-27","11483093","","2023-07-27","7/27/2023 Added new location to CAQH profile.  CAQH reviewed and re-attested.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-07-27","11483093","","2023-07-27","7/27/2023 Added new location to CAQH profile.  CAQH reviewed and re-attested.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-07-27","11483093","","2023-07-27","7/27/2023 Added new location to CAQH profile.  CAQH reviewed and re-attested.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-07-27","11483093","","2023-07-27","7/27/2023 Added new location to CAQH profile.  CAQH reviewed and re-attested.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-07-01","","","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 679507.  DCannon"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2013-12-27","1023520830","463131679","2020-08-18","Confirmed provider is participating under delegated agreement for PPO and H&W Networks (list of networks attached). Kim Frazier"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","","","2020-09-11",""]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-20","","","2021-03-24","3/24/2021 Confirmed provider is already certified as a non-network provider. KFrazier"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing the follow up complete note - Stacey Hudak"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2018-05-02","1023520830","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-11-10","","","2021-09-14","9/14/2021 Per Tricare portal, provider is participating with TaxID as of 11/10/2020. Cbankston"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2020-07-21","07/21/20220 - Rec'd email confirmation that this name change has been completed. Signed into PECOS to verify - Stacey Hudak"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1023520830","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-06-15","1023520830","","2020-10-05","Enrolled thru PHCS"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-06-15","1023520830","52669: West Texas Physicians Alliance Group Cntrct","2020-03-11","03/11/2020 - Rec'd email response from the payer stating provider is effective with different networks/effective dates as follows:\n\"Network:  MPI \nNetwork Participation effective: 10/01/2019 Group contract through: West Texas Physicians Alliance\n\nNetwork:  PHCS\nNetwork Participation effective: 06/15/2018 Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech St.\nNetwork Participation effective: 11/27/2019 Group contract through: West Texas Physicians Alliance\"\n\nAll are linked to group TIN - Stacey Hudak"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-10","14145595","","2023-05-10","5/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2018-03-19","382485601","079837301","2023-05-10","5/10/2023 Rcvd TX Medicaid revalidation approval letter.  Provider is PAR and linked to group.  TPI # 1023520830 - effective 3/19/2018.  DCannon"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-07-11","1023520830","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",43250,"1023520830","","2020-06-05","06/05/2020 - Rec'd email from payer stating this provider is EFF - Stacey Hudak"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44011,"1023520830","","2020-07-09","07/09/2020 - Rec'd welcome letter from Multiplan stating provider is covered for all governmental payers - Amerigroup is covered (STAR, Star Plus, Star Kids) - Stacey Hudak"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",43970,"12623755","","2021-08-05","7/26/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 5/19/2020 with assigned provider number 12623755. KFrazier"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44075,"1023520830","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this providers name update from Brown to Reeves has been completed EFF 9-1-2020 - Stacey Hudak"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2018-05-01","3128029","","2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 5/1/2018 PID # 3128029\ntisha rader"]
["Lori Ann Reeves",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","IMS is complete"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1104237015","","2020-06-05","06/05/2020 -Rec'd email from the payer stating provider is EFF - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2017-09-01","3094146","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2017 PID # 3094146\ntisha rader"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","2018-07-01","1790767119","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2018-07-11","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1104237015","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2018-08-01","1104237015","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 08/01/2018 under the group and TIN#. Provider is direct contract with Aertna. Physical location is on file. Call ref# 5309689188. - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-16","1104237015","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with HMO/PPO only products with this TIN/Service Location- Stacey Hudak\n\n**Verified that this provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nPPO Limited Benefit Network"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2018-06-19","","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of  6/19/2018. – Elonah Grace B. Gelig"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-13","1104237015","","2020-08-27","08/27/2020 - Rec'd email back from the payer stating \"Thank you for contacting our Customer Service Department with Multiplan/PHCS. We received your request have confirmed that the following providers are participating with Multiplan and PHCS through Midland Pediatric Associates: - Coby Robins-Effective 08/13/2018\"  - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-07-11","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating effective 7/11/2018 with the correct practice location. Kimberly Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2023-06-05","14218808","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2018-07-18","1104237015","","2020-07-15","07/15/2020 - Rec'd email through Humana Secure Mailbox stating \"i have attached a small roster with providers still active under that tin but also not on your roster.\"  I confirmed that this provider does remain effective with our group - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete","2018-07-31","1104237015","752133441","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kim Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","United Health Care","Participating","Enrollment Complete","2017-09-17","1104237015","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2018-08-13","1104237015","","2020-10-05","Enrollment thru PHCS"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2018-10-11","1104237015","","2020-04-15","04/15/2020 - Rec'd follow up team statement saying \"S/W Francis of Cigna@ 8008824462, provider NPI is on file for the provider and participating effective 10/11/18 under the group and TIN with Direct contract. Physical location is on file. Call ref# FRANCIS04142020. \"  PROVIDER IS PART OF A DIRECT CONTRACT - Stacey Hudak"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","","","2023-09-06","Confirmed this provider was added. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/1/2022.  PID # 2E0739.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to Scott & White to check status of August delegated roster provider loads.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-24",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-13","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-13","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-13","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-13","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-13","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-13","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00274901","","2022-06-11","Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00274901 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00274901","","2022-06-11","Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00274901 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00274901","","2022-06-11","Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00274901 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00274901","","2022-06-11","Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00274901 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00274901","","2022-06-11","Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00274901 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00274901","","2022-06-11","Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00274901 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate 6950 Eastridge location, so enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate 6950 Eastridge location, so enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate the 6301 Andrews Hwy location. Enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate the 6301 Andrews Hwy location. Enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate 6950 Eastridge location, so enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate 6950 Eastridge location, so enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate the 6301 Andrews Hwy location. Enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate the 6301 Andrews Hwy location. Enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate 6950 Eastridge location, so enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate 6950 Eastridge location, so enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate the 6301 Andrews Hwy location. Enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-26","Tricare is unable to validate the 6301 Andrews Hwy location. Enrollment cannot be completed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-08-16","8/16/2023 Roster submitted to add provider to new locations.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-12-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-12-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-12-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-12-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-12-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-12-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",44725,"","","2022-09-27","9/27/2022 Per follow-up note -  Provider NPI# is on file and in network with USA MCO. Link to the group and TIN# effective 6/13/2022. Location is on file, Provider ID is 1334093. Next recredentialing date is 6/13/2025. DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",44725,"","","2022-09-27","9/27/2022 Per follow-up note -  Provider NPI# is on file and in network with USA MCO. Link to the group and TIN# effective 6/13/2022. Location is on file, Provider ID is 1334093. Next recredentialing date is 6/13/2025. DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",44725,"","","2022-09-27","9/27/2022 Per follow-up note -  Provider NPI# is on file and in network with USA MCO. Link to the group and TIN# effective 6/13/2022. Location is on file, Provider ID is 1334093. Next recredentialing date is 6/13/2025. DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",44725,"","","2022-09-27","9/27/2022 Per follow-up note -  Provider NPI# is on file and in network with USA MCO. Link to the group and TIN# effective 6/13/2022. Location is on file, Provider ID is 1334093. Next recredentialing date is 6/13/2025. DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",44725,"","","2022-09-27","9/27/2022 Per follow-up note -  Provider NPI# is on file and in network with USA MCO. Link to the group and TIN# effective 6/13/2022. Location is on file, Provider ID is 1334093. Next recredentialing date is 6/13/2025. DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-13","","","2022-09-27","9/27/2022 Per follow-up note -  Provider NPI# is on file and in network with USA MCO. Link to the group and TIN# effective 6/13/2022. Location is on file, Provider ID is 1334093. Next recredentialing date is 6/13/2025. DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-06-13","1334093","","2022-08-23","08/23/2022 - Per follow-up note - Per email response received from Corvel Healthcare Corp on 08/17/2022. Provider NPI# is on file active and par under the TIN and Group effective 06/13/2022. Physical location is on file. Provider ID 1334093.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-06-13","1334093","","2022-08-23","08/23/2022 - Per follow-up note - Per email response received from Corvel Healthcare Corp on 08/17/2022. Provider NPI# is on file active and par under the TIN and Group effective 06/13/2022. Physical location is on file. Provider ID 1334093.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-06-13","1334093","","2022-08-23","08/23/2022 - Per follow-up note - Per email response received from Corvel Healthcare Corp on 08/17/2022. Provider NPI# is on file active and par under the TIN and Group effective 06/13/2022. Physical location is on file. Provider ID 1334093.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-06-13","1334093","","2022-08-23","08/23/2022 - Per follow-up note - Per email response received from Corvel Healthcare Corp on 08/17/2022. Provider NPI# is on file active and par under the TIN and Group effective 06/13/2022. Physical location is on file. Provider ID 1334093.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-06-13","1334093","","2022-08-23","08/23/2022 - Per follow-up note - Per email response received from Corvel Healthcare Corp on 08/17/2022. Provider NPI# is on file active and par under the TIN and Group effective 06/13/2022. Physical location is on file. Provider ID 1334093.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-06-13","1334093","","2022-08-23","08/23/2022 - Per follow-up note - Per email response received from Corvel Healthcare Corp on 08/17/2022. Provider NPI# is on file active and par under the TIN and Group effective 06/13/2022. Physical location is on file. Provider ID 1334093.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-27",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-27",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-27",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-27",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-27",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-27",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45047,"","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45047,"","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45047,"","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45047,"","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",44725,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",44725,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",44725,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",44725,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45170,"","","2023-09-06","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45170,"","","2023-09-06","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45170,"","","2023-09-06","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45170,"","","2023-09-06","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45170,"","","2023-09-06","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45170,"","","2023-09-06","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",44725,"","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",44725,"","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",44725,"","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",44725,"","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",44725,"","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",44725,"","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-07","See status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-07","See status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-07","See status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-07","See status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-07","See status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-07","See status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-08-16","8/16/2023 Roster submitted to add provider to new locations.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-19","6910036","","2023-09-19","09.19.2023 S/W Joe of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 06/19/2023. PIN: 6910036. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163696629. - Willie Ravas"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2022-09-16","9/16/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2022-09-16","9/16/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2022-09-16","9/16/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2022-09-16","9/16/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2022-09-16","9/16/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-06-13","","","2022-09-16","9/16/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","6910036","","2022-07-28","7/28/2022 Per follow-up note:  07.14.22. S/W Rachel of Aetna @ 1-800-353-1232. Provider NPI# is on file for the provider and is participating effective 07/01/22 under the group and TIN#. PIN 6910036. Physical location is on file. Ref# 6100299498 - Ria Dee Bieren  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","6910036","","2022-07-28","7/28/2022 Per follow-up note:  07.14.22. S/W Rachel of Aetna @ 1-800-353-1232. Provider NPI# is on file for the provider and is participating effective 07/01/22 under the group and TIN#. PIN 6910036. Physical location is on file. Ref# 6100299498 - Ria Dee Bieren  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","6910036","","2022-07-28","7/28/2022 Per follow-up note:  07.14.22. S/W Rachel of Aetna @ 1-800-353-1232. Provider NPI# is on file for the provider and is participating effective 07/01/22 under the group and TIN#. PIN 6910036. Physical location is on file. Ref# 6100299498 - Ria Dee Bieren  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","6910036","","2022-07-28","7/28/2022 Per follow-up note:  07.14.22. S/W Rachel of Aetna @ 1-800-353-1232. Provider NPI# is on file for the provider and is participating effective 07/01/22 under the group and TIN#. PIN 6910036. Physical location is on file. Ref# 6100299498 - Ria Dee Bieren  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","6910036","","2022-07-28","7/28/2022 Per follow-up note:  07.14.22. S/W Rachel of Aetna @ 1-800-353-1232. Provider NPI# is on file for the provider and is participating effective 07/01/22 under the group and TIN#. PIN 6910036. Physical location is on file. Ref# 6100299498 - Ria Dee Bieren  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","6910036","","2022-07-28","7/28/2022 Per follow-up note:  07.14.22. S/W Rachel of Aetna @ 1-800-353-1232. Provider NPI# is on file for the provider and is participating effective 07/01/22 under the group and TIN#. PIN 6910036. Physical location is on file. Ref# 6100299498 - Ria Dee Bieren  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/13/2022.  PID # 3567571.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/13/2022.  PID # 3567571.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/13/2022.  PID # 3567571.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/13/2022.  PID # 3567571.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/13/2022.  PID # 3567571.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/13/2022.  PID # 3567571.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete",44725,"","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete",44725,"","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete",44725,"","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",45047,"","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",45047,"","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",45047,"","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-11","Provider is already par with Texas Mutual. Emailed wwtxcontracts@texasmutual.com requesting to add additional locations.  Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-11","Provider is already par with Texas Mutual. Emailed wwtxcontracts@texasmutual.com requesting to add additional locations.  Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-11","Provider is already par with Texas Mutual. Emailed wwtxcontracts@texasmutual.com requesting to add additional locations.  Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-11","Provider is already par with Texas Mutual. Emailed wwtxcontracts@texasmutual.com requesting to add additional locations.  Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-11","Provider is already par with Texas Mutual. Emailed wwtxcontracts@texasmutual.com requesting to add additional locations.  Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-11","Provider is already par with Texas Mutual. Emailed wwtxcontracts@texasmutual.com requesting to add additional locations.  Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",44725,"","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",44725,"","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",44725,"","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",44725,"","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",44725,"","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-13","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44725,"008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44725,"008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44725,"008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",44725,"","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",44725,"","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",44725,"","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",44725,"","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",44725,"","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to UHC to check status of August delegated roster provider loads.  PR-7623698.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-07-24"," 7/24/2023 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",44725,"","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",44725,"","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",44725,"","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2022-06-13","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",44725,"","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-09-19","Emailed Michelle Killough for status. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-09-19","Emailed Michelle Killough for status. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-09-19","Emailed Michelle Killough for status. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-09-19","Emailed Michelle Killough for status. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-09-19","Emailed Michelle Killough for status. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-09-19","Emailed Michelle Killough for status. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45047,"","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45047,"","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45047,"","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",44725,"","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",44725,"","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",44725,"","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",44725,"","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-08-16","8/16/2023 Roster submitted to add provider to new locations.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2023-01-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2023-01-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2023-01-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2023-01-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2023-01-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2023-01-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2023-05-17","received approval letter from Careworks effective 5/17/2023. MS."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2023-05-17","received approval letter from Careworks effective 5/17/2023. MS."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2023-05-17","received approval letter from Careworks effective 5/17/2023. MS."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2023-05-17","received approval letter from Careworks effective 5/17/2023. MS."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2023-05-17","received approval letter from Careworks effective 5/17/2023. MS."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-11-08","","","2023-05-17","received approval letter from Careworks effective 5/17/2023. MS."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-01",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Add Info Submitted","","","","2023-09-19","Submitted requested information. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","8/17/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-11","Added location and re-attested. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-11","Added location and re-attested. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-11","Added location and re-attested. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-11","Added location and re-attested. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-11","Added location and re-attested. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45082,"","",45180,"Added location and re-attested. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-07-22",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2022-05-27","5/27/2022 Rcvd Medicare approval letter.  PTAN # 2E0739 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2022-05-27","5/27/2022 Rcvd Medicare approval letter.  PTAN # 2E0739 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",44682,"2E0739","423838","2022-05-27","5/27/2022 Rcvd Medicare approval letter.  PTAN # 2E0739 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2022-05-27","5/27/2022 Rcvd Medicare approval letter.  PTAN # 2E0739 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2022-05-27","5/27/2022 Rcvd Medicare approval letter.  PTAN # 2E0739 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2E0739","423838","2022-05-27","5/27/2022 Rcvd Medicare approval letter.  PTAN # 2E0739 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2023-08-02","Rcvd approval letter from TMHP. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2023-04-14","","","2023-07-26","7/26/2023 Per email received from IMS/OMNI February delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-04-14","","","2023-07-12","Received confirmation email from rep. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Per the Coventry website - 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.   The following payers fall under Coventry - Travelers, Liberty Health, Hartford, WorkWell-TX, Zurich.    DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2023-05-19","","","2023-07-18","Michelle Killough confirmed provider is effective 5/19/2023. MS See Alliance for enrollment note updates."]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","In Process","Pending Contracting","","","","2023-06-12","Per response from SPNEast@Sedgwickcms.com they are unable to find TIN 46-3131679 in their inventory. Contact contracting team to obtain a contract.  Emailed PPOContracting@Careworks.com for next steps in obtaining contract and getting individual credentialed. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2023-04-14","","","2023-07-20","7/20/2023 Per email received from Galaxy April  delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2023-04-14","","","2023-05-31","05.31.2023 S/W Anthony of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 04/14/2023. Provider ID 9850849, Payer ID 60054 and Recredentialing date is not required due to provider is delegated. Service location is on file. Call ref#:6149186847. - Danico Gabriel Melendres"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","In Process","Pending Contracting","","","","2023-08-22","Per Benjamin Richbourg benjamin.richbourg@primehealthservices.com, Midland Texas Orthopedic Group is not contracted and needs a signed agreement and HCN addendum. Emailed agreement and addendum to Priscilla and Neeraja. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Per the Coventry website - 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.   The following payers fall under Coventry - Travelers, Liberty Health, Hartford, , Zurich.    DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-04-25","4/25/2023 Pending UHC enrollment.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Per the Coventry website - 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.   The following payers fall under Coventry - Travelers, Liberty Health, Hartford, WorkWell-TX, Zurich.    DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-08-21","Received confirmation. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2T0202","","2023-05-10","5/10/2023 Rcvd Medicare approval letter.  PTAN # 2T0202 - effective 5/1/2023.   DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2023-07-01","","","2023-09-15","Received confirmation email with effective date. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","In Process","Action Needed","","","","2023-08-24","Rep informed me the provider needs to be recertified. Electronic application can be completed on their website. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete",45065,"","","2023-05-22","Michelle Killough confirmed provider is effective 5/19/2023. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","In Process","Payor Follow Up","","","","2023-09-01","9/1/2023 Sent follow-up email to Marcus Wester at Humana to check status of June monthly delegated roster submission.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested",45042,"","",45042,"4/26/2023 CAQH profile reviewed, updated practice address information, malpractice information and credentialing contact.  CAQH profile reviewed and re-attested.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete",45030,"","",45098,"Rcvd effective date of 4/14/2023 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","In Process","Payor Follow Up","","","","2023-09-05","9/5/2023 Sent follow-email to UHC to check status of April delegated roster.  Reference: PR-7418966.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Pending First Health enrollment.  DCannon\n07/18/2023. 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"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2023-04-25","4/25/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2023-08-01","","","2023-08-08","Rcvd approval letter. Effective 08/01/2023. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2023-04-14","","","2023-07-26","7/26/2023 Per email received from IMS/OMNI April delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-18",""]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-04-14","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from April has been completed and provider is PAR effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2023-04-14","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Hartford","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Per the Coventry website - 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.   The following payers fall under Coventry - Travelers, Liberty Health, Hartford, WorkWell-TX, Zurich.    DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Travelers WC","Panel Closed","Panel Closed","","","","2023-04-26","4/26/2023 Per the Coventry website - 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.   The following payers fall under Coventry - Travelers, Liberty Health, Hartford, WorkWell-TX, Zurich.    DCannon"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2018-07-31","1740542034","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-09-20","1740542034","","2020-08-20","08/20/2020 - Rec'd emailed spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-07-27","1740542034","","2020-06-10","06/10/2020 - Rec'd email from the payer stating provider is EFF - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2018-07-31","1740542034","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice)  stating this provider is EFF at this service location with Amerigroup - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2018-09-01","1740542034","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1740542034","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2018-08-16","1740542034","","2020-09-08","09/08/2020 - Found response from the payer stating \"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Multiple providers listed below:\n\nNetwork: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\nRyan S Rowland, MD NPI: 1740542034 – \n5026 – West Texas Physicians Alliance –  Beech St Eff Date 07/11/2018\n23655 – West Texas Physicians Alliance –  MPI Eff Date 08/16/2018\n52669 – West Texas Physicians Alliance – PHCS Eff Date 08/16/2018\" - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note from 8/28/2020 - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-08-01","3165726","","2020-03-20","03/20/2020 - Recd email from the payer stating this provider is effective under PID# 3165726  - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete",43305,"1740542034","","2020-06-26","06/26/2020 - EFF IF IMS IS EFF - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2018-08-01","1740542034","","2020-04-23","04/23/2020--S/W Kim of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 8/1/2018. Physical Location is on file. Provider ID #6404238. Call ref # 5234162545\ncopied note from spreadsheet-tisha rader"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-05-20","1346807278","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2020-08-01","1346807278","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2020-05-13","1346807278","","2020-09-08","09/08/2020 - Rec'd email response from the payer stating \" Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below:\n\nPamela F Doughty, PA NPI: 1346807278\n5026 – West Texas Physicians Alliance –Beech St Eff Date 05/06/2020\n23655 – West Texas Physicians Alliance – MPI Eff Date 05/13/2020\n52669 – West Texas Physicians Alliance – PHCS Eff Date 05/13/2020\"\n- Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","In House Enrollment","2020-01-05","412587401","325373401","2020-08-13","8/13/2020 - rec'd effective letter from the clinic. HOwever, this is not a payer that they asked Symplr to maintain. Created a payer line to house effective info if needed by another payer for enrollment - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2021-01-26","1312287","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2020-12-10","12/10/2020 - Per First Health provider is active and linked to practice location effective 9/1/2020.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-09-01","1346807278","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2020-05-06","13725946","","2020-07-21","07/21/2020 - rec'd email with a spreadsheet from the payer stating this provider/TIN/service location are all PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 4/15/2020.  DCannon"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete","2020-09-01","1346807278","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is now participating under group Tax ID effective 9/1/2020 and assigned PIN number 6962996. Kimberly Frazier"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-10-26","1649462987","475554737","2020-08-18","Confirmed provider is participating with PPO and H&W Networks (list of networks attached). Kimberly Frazier"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-04-19","","","2023-04-19","4/19/2023 CAQH reviewed and re-attested.  DCannon"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1649462987","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-08-01","1649462987","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2018-10-01","2506877","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 2506877 - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2018-11-15","1649462987","","2020-02-03","02/03/2020 - Rec'd confirmation from the follow up team that this provider is \"in network-participating-DIRECT contracted\" EFF 11-15-2018. Unfortunately, no reval date was provided, but it was confirmed that this service location is linked to the provider. - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-08-01","685085","519061","2020-04-22","04/22/2020 - found EFF info through group PECOS enrollment - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-26","1649462987","","2020-08-19","8/19/2020 - Rec'd a new spreadsheet from Baylor Scott & White after they merged databases with First Care. Updated the effective date and this provider is showing up affilaited with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-08-01","P02179384","DW7662","2020-04-22","04/22/2020 - Confirmed provider EFF info through payer portal - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2018-12-01","1649462987","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 12-1-2018  **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-11-30","1649462987","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-10-22","","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1407149883","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-02-12","1407149883","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-03-10","","","2023-03-10","3/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-11-30","1407149883","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2018-10-01","3060094","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 3060094 - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-08-01","1407149883","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 8-1-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-08-27","1407149883","","2020-09-23","09/23/2020 - Reviewed follow up complete note and moved to completed status - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-09-01","P02262526","","2020-03-25","3/25/2020--Per online check, provider is now PAR effective 09/01/2018 with provider number P02262526. Attached welcome letter to payor line\n--tisha rader"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-06-05","060/5/2020 - Rec'd email from the payer stating this provider is EFF - Stacey HUdak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2018-12-01","1407149883","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 12-1-2018 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2018-09-01","377470502","364596201","2023-08-22","Revalidation approval ltr rcvd via TMHP website. Effective 09/01/2018. Jen Videan"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-25",""]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-09-01","691156","519061","2020-02-19","02/19/2020 - Rec'd PECOS login .Signed in to find that this provider is successfully enrolled with Medicare/MIMA as of 9-1-2018. - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-10-26","1407149883","475554737","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-08-01","1407149883","","2020-07-30","7/30/2020 - moved to completed status after reviewing followup complete note - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2018-11-15","1407149883","","2020-02-03","02/03/2020 - Rec'd confirmation from the follow up team that this provider is \"in network-participating-DIRECT contracted\" EFF 11-15-2018. Unfortunately, no reval date was provided, but it was confirmed that this service location is linked to the provider. - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2018-10-22","1407149883","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-08-27","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 8/27/2020.  DCannon"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2018-12-19","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, 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"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2018-10-26","1326061086","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-10-01","1397856","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 10/01/2018 PID # 1397856\ntisha rader"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","USA PPO","Participating","Enrollment Complete","2018-10-26","1326061086","752302928","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1326061086","","2020-07-20","7/20/2020- Received a spreadsheet from the payer stating this provider is effective as of 10/26/2018. – Jerha Gayorgor"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2015-12-17","1326061086","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with this TIN/Service Location- Stacey Hudak\n\n**Verified with the payer that this provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2018-11-15","1326061086","","2020-06-09","06/09/2020 - S/W Bella of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 11/15/2018 under the group and TIN#. Provider is DELEGATED TO PRIMED  Network. Physical location is on file. Call ref# 5309719262. - Stacey Hudak"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete",43453,"","","2020-11-03","11/3/2020 Confirmed via self-service portal provider has been completed effective 12/19/2018. Kimberly Frazier"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2023-06-05","10450267","","2023-06-05","6/5/2023 - CAQH Reattested by Data Services Team - kavello"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","2018-10-22","1326061086","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Cigna","Participating","Enrollment Complete","2008-11-01","1326061086","","2020-04-22","04/22/2020--SW Red of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 11/1/2018. Location is on file. Call ref# red4202020.\n-copied note from spreadsheet-tisha rader"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Humana","Participating","Enrollment Complete","2018-10-22","1326061086","","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"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Boon Chapman","Participating","Enrollment Complete","2018-09-18","1326061086","","2020-10-05","Enrolled through PHCS"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2018-09-18","1326061086","","2020-08-27","08/27/2020 - Rec'd email from the payer stating this provider \"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: - Kevin Benson-Effective 09/18/2018\" - Stacey Hudak"]
["Kevin W Benson, MD",1326061086,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-10-22","1326061086","","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"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","2018-01-16","560990YSCJ","290001","2020-07-24","7/24/2020 - Confirmed this provider is linked to Quick Care Clinic Part B group PTAN 290001 - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Boon Chapman","Participating","Enrollment Complete","2020-07-17","","","2022-09-15","9/15/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Molina","Pending Other Enrollment","Payor Follow Up","","","","2023-09-15","9/15/2023 Rcvd email response from Margaret White at Molina directing me to reach out to MHTContractRequest@molinahealthcare.com.  Forward original email request submitted back in 2021 to follow-up on request.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-07-17","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2021-01-13","01/06/2021 - MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2020-10-01","1740723725","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the PriMed roster - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2018-07-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 7/1/2018.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2020-09-01","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2018-04-30","1740723725","","2020-07-23","07/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-26","1312289","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2023-05-16","05.16.2023 S/W Jerome of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 09/01/2020. Provider ID 3385653, No Payer ID and No Recredentialing date. Service location is on file. call ref#:633322.-Danico Gabriel Melendres"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2020-07-17","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/17/2020.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-02","1740723725","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer stating this provider has been added to the PRIMED DELEGATED AGREEMNT under this TIN/Service Location. The provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1740723725","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","1740723725","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2018-04-01","","","2020-09-24","Confirmed via self-service portal, provider is participating under group Tax ID and location. Kimberly Frazier"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Participating","Enrollment Complete","2018-01-16","378143702","324676101","2021-02-10","2/10/2021 Per email received from Stacy Salazar, she processed provider's application, which has been approved and assigned TPI 378143702 effective 1/16/2018. KFrazier"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-07-17","","","2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 7/17/2021.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1740723725","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2023-04-04","","","2022-12-15","12/15/2022 CAQH re-attested.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","","CAQH","Participating","CAQH Reattested",45020,"","","2022-12-15","12/15/2022 CAQH re-attested.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested",45020,"","","2023-04-04","4/4/2023 CAQH reviewed and re-attested.  DCannon"]
["Ubaldo Estrada, FNP",1740723725,"75-1997880","TX","","CAQH","Participating","CAQH Reattested",45020,"","","2023-04-04","4/4/2023 CAQH reviewed and re-attested.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44592,"007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-01-31","007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-01-31","007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-01-31","007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-01-31","007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-01-31","007021658","","2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider is complete. MPIN 007021658. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2021-12-08","12/8/2021 Per email from Mary Hanna @ Aetna provider is PAR and linked to group/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2021-12-08","12/8/2021 Per email from Mary Hanna @ Aetna provider is PAR and linked to group/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2021-12-08","12/8/2021 Per email from Mary Hanna @ Aetna provider is PAR and linked to group/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2021-12-08","12/8/2021 Per email from Mary Hanna @ Aetna provider is PAR and linked to group/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2021-12-08","12/8/2021 Per email from Mary Hanna @ Aetna provider is PAR and linked to group/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","","","2021-12-08","12/8/2021 Per email from Mary Hanna @ Aetna provider is PAR and linked to group/locations effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2022-04-01","","","2022-04-07","4/7/2022 Received welcome letter from wwtxcontracts@texasmutual.com, provider is par and eff 4/1/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2022-04-01","","","2022-04-07","4/7/2022 Received welcome letter from wwtxcontracts@texasmutual.com, provider is par and eff 4/1/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2022-04-01","","","2022-04-07","4/7/2022 Received welcome letter from wwtxcontracts@texasmutual.com, provider is par and eff 4/1/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2022-04-01","","","2022-04-07","4/7/2022 Received welcome letter from wwtxcontracts@texasmutual.com, provider is par and eff 4/1/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2022-04-01","","","2022-04-07","4/7/2022 Received welcome letter from wwtxcontracts@texasmutual.com, provider is par and eff 4/1/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2022-04-01","","","2022-04-07","4/7/2022 Received welcome letter from wwtxcontracts@texasmutual.com, provider is par and eff 4/1/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","2023-01-09","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 11/1/2022. Location is on file. Provider ID is 3208919. Next recredentialing date is every 3 years (11/1/2025). No information for the payer#. -Kim Monique Fabian. -Kim Monique Fabian"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","2023-01-09","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 11/1/2022. Location is on file. Provider ID is 3208919. Next recredentialing date is every 3 years (11/1/2025). No information for the payer#. -Kim Monique Fabian. -Kim Monique Fabian"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","2023-01-09","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 11/1/2022. Location is on file. Provider ID is 3208919. Next recredentialing date is every 3 years (11/1/2025). No information for the payer#. -Kim Monique Fabian. -Kim Monique Fabian"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","2023-01-09","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 11/1/2022. Location is on file. Provider ID is 3208919. Next recredentialing date is every 3 years (11/1/2025). No information for the payer#. -Kim Monique Fabian. -Kim Monique Fabian"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","2023-01-09","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 11/1/2022. Location is on file. Provider ID is 3208919. Next recredentialing date is every 3 years (11/1/2025). No information for the payer#. -Kim Monique Fabian. -Kim Monique Fabian"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Enrollment Complete","","","","2023-01-09","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 11/1/2022. Location is on file. Provider ID is 3208919. Next recredentialing date is every 3 years (11/1/2025). No information for the payer#. -Kim Monique Fabian. -Kim Monique Fabian"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-09-19","Emailed SPNEAST@sedgwickcms.com for status. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-09-19","Emailed SPNEAST@sedgwickcms.com for status. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-09-19","Emailed SPNEAST@sedgwickcms.com for status. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-09-19","Emailed SPNEAST@sedgwickcms.com for status. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-09-19","Emailed SPNEAST@sedgwickcms.com for status. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-09-19","Emailed SPNEAST@sedgwickcms.com for status. Jen Videan"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-01-12","1277846","","2022-02-24","02/24/2022 Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and is participating under the group and TIN effective 01/12/2022. PIN# 1277846. Next recredentialing date is on 01/12/2025. Physical location is on file. No Payer#. Call ref#  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-01-12","1277846","","2022-02-24","02/24/2022 Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and is participating under the group and TIN effective 01/12/2022. PIN# 1277846. Next recredentialing date is on 01/12/2025. Physical location is on file. No Payer#. Call ref#  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-01-12","1277846","","2022-02-24","02/24/2022 Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and is participating under the group and TIN effective 01/12/2022. PIN# 1277846. Next recredentialing date is on 01/12/2025. Physical location is on file. No Payer#. Call ref#  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-01-12","1277846","","2022-02-24","02/24/2022 Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and is participating under the group and TIN effective 01/12/2022. PIN# 1277846. Next recredentialing date is on 01/12/2025. Physical location is on file. No Payer#. Call ref#  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-01-12","1277846","","2022-02-24","02/24/2022 Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and is participating under the group and TIN effective 01/12/2022. PIN# 1277846. Next recredentialing date is on 01/12/2025. Physical location is on file. No Payer#. Call ref#  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-01-12","1277846","","2022-02-24","02/24/2022 Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and is participating under the group and TIN effective 01/12/2022. PIN# 1277846. Next recredentialing date is on 01/12/2025. Physical location is on file. No Payer#. Call ref#  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-09-26","9/26/2021 Processed in-house through BCBSTX. KFrazier"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-09-26","9/26/2021 Processed in-house through BCBSTX. KFrazier"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-09-26","9/26/2021 Processed in-house through BCBSTX. KFrazier"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-09-26","9/26/2021 Processed in-house through BCBSTX. KFrazier"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-09-26","9/26/2021 Processed in-house through BCBSTX. KFrazier"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-09-26","9/26/2021 Processed in-house through BCBSTX. KFrazier"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2021-09-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 9/1/2021. DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","",45008,"3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","",45008,"3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","",45008,"3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","",44518,"11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-09-01","","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from October has been completed and provider is PAR effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-09-01","","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from October has been completed and provider is PAR effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-09-01","","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from October has been completed and provider is PAR effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-09-01","","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from October has been completed and provider is PAR effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-09-01","","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from October has been completed and provider is PAR effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-09-01","","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from October has been completed and provider is PAR effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-09-01","","","2021-09-26","9/26/2021 Group is contracted as an ancillary facility, so no enrollment is required. KFrazier"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-09-01","","","2021-09-26","9/26/2021 Group is contracted as an ancillary facility, so no enrollment is required. KFrazier"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-09-01","","","2021-09-26","9/26/2021 Group is contracted as an ancillary facility, so no enrollment is required. KFrazier"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-09-01","","","2021-09-26","9/26/2021 Group is contracted as an ancillary facility, so no enrollment is required. KFrazier"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-09-01","","","2021-09-26","9/26/2021 Group is contracted as an ancillary facility, so no enrollment is required. KFrazier"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-09-01","","","2021-09-26","9/26/2021 Group is contracted as an ancillary facility, so no enrollment is required. KFrazier"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-09-01","Q00157212","","2021-11-02","11/2/21 Effective 9/1/21, PTAN Q00157212. Please allow three business days for the activation of this new PTAN. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-09-01","Q00157212","","2021-11-02","11/2/21 Effective 9/1/21, PTAN Q00157212. Please allow three business days for the activation of this new PTAN. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-09-01","Q00157212","","2021-11-02","11/2/21 Effective 9/1/21, PTAN Q00157212. Please allow three business days for the activation of this new PTAN. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-09-01","Q00157212","","2021-11-02","11/2/21 Effective 9/1/21, PTAN Q00157212. Please allow three business days for the activation of this new PTAN. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-09-01","Q00157212","","2021-11-02","11/2/21 Effective 9/1/21, PTAN Q00157212. Please allow three business days for the activation of this new PTAN. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-09-01","Q00157212","","2021-11-02","11/2/21 Effective 9/1/21, PTAN Q00157212. Please allow three business days for the activation of this new PTAN. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-09-01","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2021-10-01","10/1/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN # 1U8148 - effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2021-10-01","10/1/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN # 1U8148 - effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2021-10-01","10/1/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN # 1U8148 - effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2021-10-01","10/1/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN # 1U8148 - effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2021-10-01","10/1/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN # 1U8148 - effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-09-01","1U8148","423838","2021-10-01","10/1/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN # 1U8148 - effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-19","09/19/2023. 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"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-01-14","","","2022-02-28","2/28/2022 Received email from michelle.killough@pswca.org, provider is par with location eff 1/14/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-01-14","","","2022-02-28","2/28/2022 Received email from michelle.killough@pswca.org, provider is par with location eff 1/14/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-01-14","","","2022-02-28","2/28/2022 Received email from michelle.killough@pswca.org, provider is par with location eff 1/14/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-01-14","","","2022-02-28","2/28/2022 Received email from michelle.killough@pswca.org, provider is par with location eff 1/14/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-01-14","","","2022-02-28","2/28/2022 Received email from michelle.killough@pswca.org, provider is par with location eff 1/14/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-01-14","","","2022-02-28","2/28/2022 Received email from michelle.killough@pswca.org, provider is par with location eff 1/14/2022. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2021-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2021.  DCannon"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-12-17","","","2022-01-04","1/4/2022 Per Tricare portal, provider is linked to locations as of 12/17/2021. Cbankston"]
["Morgan Sims, PA-C",1952865057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-12-17","","","2022-01-04","1/4/2022 Per Tricare portal, provider is linked to locations as of 12/17/2021. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-12-17","","","2022-01-04","1/4/2022 Per Tricare portal, provider is linked to locations as of 12/17/2021. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: S","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-12-17","","","2022-01-04","1/4/2022 Per Tricare portal, provider is linked to locations as of 12/17/2021. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-12-17","","","2022-01-04","1/4/2022 Per Tricare portal, provider is linked to locations as of 12/17/2021. Cbankston"]
["Morgan Sims, PA-C",1952865057,"473465832: T","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-12-17","","","2022-01-04","1/4/2022 Per Tricare portal, provider is linked to locations as of 12/17/2021. Cbankston"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-03-01","774291","320497","2021-09-10","9/10/2021 Received written revalidation approval for provider under provider PTAN 774291. KFrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2020-05-21","1588857874","","2020-09-23","09/23/2020 - moved to completed status after reviewing the follow up completed status - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1588857874","","2020-06-25",""]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","380896603","331090601","2020-07-15","07/15/2020 - logged into TMHP and found that this provider is EFF - TPI 380896603 - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-05-21","1588857874","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 6-1-2019 under a DIRECT CONTRACT with this payer. This service location is on file and linked to the provider. -Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2019-05-31","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 5/31/2019.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2019-09-01","1588857874","","2020-02-10","02/10/2020 - Rec'd confirmation from payer that this provider is EFF at 5615 Deauville, Ste 220 through a DELEGATED PAYER (Permian Basin Healthcare Network) and linked to the following products: STAR, HEALTH FOSTER CARE, STAR, STAR PLUS, CHIP RSA,\nSTAR KIDS, CHIP, CHIP PERINATE, also EXCHANGE (exchange only since 1-1-2014; non par) All other products are PAR since 9-1-2019. - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2019-05-31","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 5/31/2019. Kfrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-02-20","02/20/2020 - Had the follow up team call CIgna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 4-4-2019 under a DIRECT CONTRACT at this service location."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2019-11-01","","","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 11/1/2019.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2650428","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 2650428 - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-03-01","P02232681","DU5783","2020-02-21","02/12/2020 - Found effective info through payer site stating provider is PAR with group PTAN:  DU5783 EFF 3-1-2019. - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1588857874","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","","","2020-09-04","Provider is participating under group Tax ID and correct location. Kimberly Frazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 3/6/2019.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2019-05-31","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 5/31/2019. Kfrazier"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1588857874","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2019-05-21","1588857874","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2019-04-10","1588857874","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) has sent confirmation that this provider is EFF with Amerigroup - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-31","1588857874","","2020-08-19","8/19/2020 - Rec'd spreadsheet from the payer confirming this provider is linked to the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2019-04-19","1588857874","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1588857874","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-04-04","1588857874","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1588857874","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019. – Archie Candiasan"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-03-06","1164778767","","2020-02-20","02/20/2020 - Had the follow up team call CIgna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 3-6-2019 at this service location. They also said this provider IS DELEGATED; but could not say who the delegated company is. - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-02-18","779243","320497","2020-01-30","01/30/2020 - Found this provider is linked to Midland Texas Ortho (group PTAN 320497 and Employer ID# 1346681061) as of 2-18-2019. MAURENE.MCDANIEL@MIDLANDHEALTH.ORG  is the contact person - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-12-31","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"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-06-05","6/5/2023 - CAQH Reattested by Data Services Team - kavello"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2014-01-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 1/1/2014. Kfrazier"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2019-02-18","362149203","331090601","2020-02-25","02/25/2020 - Rec'd deficiency from the payer stating this provider was already enrolled with this group TPI, eventhough this provider is not showing under group portal. Asked the clinic to send over welcome letter from this payer and they did. Updated payer line with effective info - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete",43586,"3039403","","2020-03-20","03/20/2020 - Rec'd email from the payer stating this provider is EFF under PID# 3039403 - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete",44774,"","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete",43831,"1164778767","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete",43586,"","","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-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Enrollment Complete","2019-06-01","1164778767","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 6-1-2019 under a DELEGATED AGREEMENT with Permian Basin Healthcare - Effective date 8/15/2019. This service location is on file. Must contact Permian for more info - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete",43616,"1164778767","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1164778767","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2019-06-06","1164778767","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2019-11-01","1164778767","463131679","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 11/1/2019.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-04-13","","","2020-10-02","10/2/2020 - Rec'd response from the payer stating \"•\tProviders marked as \" Delegated Contract With SHP” have an active delegated contract with another entity by the same NPI & TIN through Superior Health Plan. Please note that these providers will not be accepted as part of your Delegated Opt-in. \" \nWe cannot add this provider to the PriMed delegation, as they are already with another delegated group- Stacey Hudak"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 5/1/2020.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2020-05-21","1164778767","","2020-09-23","Provider is delegated under Physician Optimal INC"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2019-05-31","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 5/31/2019.  DCannon"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2014-01-01","","","2020-07-27","7/27/2020- S/W  Jack of  Gallagher (thru Coventry) @ 800-243-2336 and she transferred the call to cred dept. S/W  Lynn  and  she confirmed group is par with Worker's Comp Network under the TAX ID eff 1/1/2014.  Provider is  par as a delegated  with Worker's Comp Network under the TAX ID eff 5/1/2019. Physical location is on file. Group ID# 2559513 and Individual ID# 3039403. Call ref#181324888. - Elonah Grace B. Gelig"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-02-18","P02405660","","2020-03-25","3/25/2020- Per online check, provider is now PAR effective 02/18/2019 with provider number P02405660. Attached welcome letter to payor line\n-tisha rader"]
["Kristin L Rettig, PA-C",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1164778767","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",43606,"1639524861","","2020-06-25",""]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1639524861","","2020-07-17","7/17/2020 - received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-09-15","","","2023-08-18","8/18/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-16","1639524861","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 4-16-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","793339","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-28","13859704","","2023-06-28","6/28/23 Confirmed updated DEA is present and added 4214 ste 102 to profile. -kavello"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-07-19","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","3041792","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 5/1/2019 PID # 3041792\ntisha rader"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","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."]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-03","1639524861","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","1639524861","752656723","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-16","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 4/16/2019.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-07-19","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2023-09-01","9/1/2023 Sent follow-up email to Marcus Wester at Humana to check status of June monthly delegated roster submission.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-04-17","","","2023-09-13","Received confirmation of enrollment via email. MS"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-07-19","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1639524861","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2017-06-26","1639524861","","2020-08-03","8/3/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","","","2023-08-25","Confirmation of location being added via provider directory. MS"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15","1639524861","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","360348204","079837301","2020-01-29","01/29/2020 - found provider through payer portal. Provider is linked to the following plans: TRADITIONAL MEDICAID, Texas Children's Health Plan - MRSA Northeast, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44089,"1639524861","",44096,"09/22/2020 - Called 800-872-3862 but routed to Aetna Corporate Center and unable to reach live rep. Called Aetna @ 800-353-1232 S/W Mark. Provider NPI# is on file for the provider and is participating effective 09/15/2020 under the group and TIN#. Physical location is on file.Call Ref# 5560576876. - Archie Candiasan"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-08-11","","","2023-08-23","Confirmed link via Tricare web portal MS"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","2017791","","2021-08-04","8/4/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 3/31/2021 with assigned provider ID number 2017791. KFrazier"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-01-05","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31","1639524861","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3-19-2020 - Rec'd email from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-07-19","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 7/19/2023.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Application Submitted","2019-08-01","1639524861","","2023-06-19","6/19/23 Roster submitted"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2020-03-01","1639524861","","2021-05-26","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"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-04","","","2023-08-21","Per TMHP website provider is active at 4214 Andrews Hwy Ste 107. Effective 08/04/2022. Jen Videan"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 10/15/2019.  DCannon"]
["Rachel K Longacre, FNP-C",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44131,"","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is approved and participating under Group Tax ID and location effective 10/27/2020. Kimberly Frazier"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","1144665233","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-26",""]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","In House Enrollment","2019-09-01","842726","270548","2020-06-29","06/29/2020 - Rec'd a copy of the Medicare EFF letter for our records to support other payer enrollment. Medicare enrollment will be maintained in-house (not my Symplr) - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2019-09-01","1144665233","","2020-09-08","09/08/2020 - Rec'd email from the payer stating:\n\"Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nW Gage Liesman, MD NPI: 1144665233\n5026 – West Texas Physicians Alliance – Eff Date 09/01/2019\n23655 – West Texas Physicians Alliance – Eff Date 09/01/2019\n52669 – West Texas Physicians Alliance – Eff Date 09/01/2019\" - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2019-09-30","1144665233","","2020-08-20","08/20/2020 - rec'd email from the payer stating this provider is affilliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. \nThis provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete","2019-08-01","1144665233","","2020-06-12","06/12/2020 - Rec'd email from the payer stating this provider is EFF - PID# 3303866 - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2019-08-30","1144665233","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR, CHIP_PERINATAL, STAR_PLUS, CHIP.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete","2020-01-01","1144665233","","2020-08-31","08/31/2020 - moved to completed status after reviewing August follow up complete note - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete",43703,"1144665233","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","In House Enrollment",43709,"404183201","","2020-06-29","06/29/2020 - client supplied us with copy of MEDICAID EFF letter for other payer enrollments, if needed. Symplr does not need to maintain this enrollment.  Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete",43739,"1144665233","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete",44075,"6694913","","2020-11-24","11/24/2020 - Per f/u report provider NPI# is on file for the provider is linked and is participating effective 09/01/2020 under the group and TIN#. Provider ID 6694913. Group ID 4907135.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete","2020-06-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-06-05","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-11-01","1932541406","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-08","13876531","","2023-06-08","06/08/2023 - Added 4214 andrews Hwy, Ste 107 to practice locations and added Mandy Stone as cred contact- kavello"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45085,"13876531","","2023-06-08","06/08/2023 - Added 4214 andrews Hwy, Ste 107 to practice locations and added Mandy Stone as cred contact- kavello"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45085,"13876531","","2023-06-08","06/08/2023 - Added 4214 andrews Hwy, Ste 107 to practice locations and added Mandy Stone as cred contact- kavello"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45085,"13876531","","2023-06-08","06/08/2023 - Added 4214 andrews Hwy, Ste 107 to practice locations and added Mandy Stone as cred contact- kavello"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",45078,"","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete",44166,"","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",43738,"1932541406","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","IMS","Participating","Enrollment Complete",45082,"","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",45082,"","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",43647,"5258891","","2023-08-16","8/16/2023 Per follow-up note - provider NPI# is on file for the provider and is participating effective 07/01/19 under the group and TIN#. Location address is on file. PIN# 5258891. DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",43648,"1932541406","","2020-09-14","Upon review of the Self-Service portal, provider is completed and loaded as participating under practice location. Kimberly Frazier"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",43570,"1932541406","","2020-07-30","7/30/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",43738,"1932541406","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Rec'd email confirmation from Multiplan/Texas True Chioce stating EFF information is correct - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",43666,"","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/20/2019.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",45078,"","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2023.  PID # 3002056.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Enrollment Complete","","","","2023-05-15","5/15/2023 Roster submitted.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",43586,"804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",43586,"804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",43586,"804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",43586,"804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",45078,"","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",45082,"","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete",45078,"","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",45127,"","","2023-09-07","9/7/2023 Per email rcvd from Scott & White delegated roster for June has been completed.  Provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",43666,"1932541406","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 7-20-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","Omni PPO","Participating","Enrollment Complete",45082,"","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43628,"1932541406","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-08-14","1932541406","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 8-14-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-06-05","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-06-05","","","2023-08-01","8/1/2023 Rcvd email confirmation that provider is PAR and linked to group/location effective 6/5/2023.  PID # 7585417.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-08-11","","","2023-08-23","8/23/2023 Per Tricare portal provider is PAR and linked to group/location effective 8/11/2023."]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2023-08-11","","","2023-08-23","8/23/2023 Per Tricare portal provider is PAR and linked to group/location effective 8/11/2023."]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Payor Follow Up","2023-08-11","","","2023-08-23","Provider is still pending for the Wall St. location. MS"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","TriCare Standard","Participating","Payor Follow Up","2023-08-11","","","2023-08-23","Provider is still pending for the Wall St. location. MS"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2019-05-01","397298601","079837301","2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-06-05","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-05-01","1932541406","","2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is under DIRECT CONTRACT EFF 5-1-2019 - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-21","","","2023-09-06","Downloaded approval letter from TMHP website. Effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12","1932541406","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-06-14",""]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-07-01","1811423981","","2020-09-09","09/09/2020 - moved to completed status after reviewing last note - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-08-30","1811423981","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - rec'd email from the payer Multiplan/Texas True Choie stating that this effective info is true - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-04-07","1811423981","","2020-07-20","07/20/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-08-26","1811423981","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","1811423981","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-08-30","1811423981","752656723","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1811423981","","2020-07-19","7/19/2020 - Received email spredsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-26","1811423981","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12","1811423981","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-01-01","","","2020-10-30","10/30/2020 Provider is certified as non-network effective 1/1/2019, as she is currently participating under group Tax ID and location is being updated. Kimberly Frazier"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-06-01","1811423981","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 4/1/2022.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-06-15","6103957","","2020-06-08","06/08/2020 - Rec'd email from the payer stating this provider is PAR with the network effective 6/15/2020. Your Provider Identification Number (PIN) is: 6103957 - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-10-01","1811423981","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-04-28","14074150","","2023-04-28","4/28/2023 CAQH reviewed and re-attested.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-08-26","1811423981","","2020-06-25",""]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-06-01","805590","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-10-23","","","2020-12-04","12/4/2020 Upon review of self-service portal provider is now participating under Group Tax ID and location. KFrazier"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-06-01","6730214","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-08-01","3304172","","2020-03-24","3/24/2020-receieved email with roster from payor stating provider PAR 8/1/2019 PID # 3304172\ntisha rader"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-07-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/1/2020.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","397315801","079837301","2020-01-29","01/29/2020 - found provider through payer portal. Provider is linked to these plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-09-30","","","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 9/30/2019.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-15","","","2020-08-25","Confirmed provider is participating under delegation effective 9/15/2019. Kimberly Frazier"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-07-17","","","2023-08-31",""]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2020-07-21","","","2021-05-26","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"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-15","","","2020-08-25","Confirmed provider is participating under delegation effective 9/15/2019. Kimberly Frazier"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-11-08","","","2021-11-30","11/30/2021 Checked portal and provide is added to location. Cbankston"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 9/26/2019.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-08-12","","","2020-12-22","12/22/2020 Upon review of the Self-Service portal, provider is participating under group Tax ID, which confirmed provider is certified as non-network provider since that's a requirement before able to become a PAR provider. KFrazier"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-07-01","","","2020-11-20","11/20/20 - Rcvd confirmation email from UHC confirming enrollment at this location.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-18","1073672994","","2020-09-24",""]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2019-07-01","129062909","","2020-08-07","8/7/2020 - rec'd welcome letter from the clinic stating this provider is EFF and linked to TIN - Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2019-09-18","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/18/2019.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-09-30","1073672994","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 9-30-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-11-01","1073672994","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-09-01","","","2020-12-09","12/9/2020 - Rcvd confirmation from payor that provider is now active and linked to this location.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1073672994","","2020-11-02","11/2/2020 - moved to completed status due to follow up note -Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-07-01","823276","","2020-08-07","8/7/2020 - moved to completed status after getting welcome letter from the clinic. No effective date was listed - Stacey Hudak"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-10","10606333","","2023-05-10","5/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","2740972","","2021-07-27","7/27/2021 Received an email from PDMCOGZ@cigna.com with confirmation of approval for participation effective 3/31/2021 with assigned provider ID 2740972. KFrazier"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 6/1/2022.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1073672994","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-09-30","1073672994","752656723","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-08-23","","","2021-03-15","3/15/2021 Rcvd email from Christelle Tchampo at Scott & White confirming provider is participating under TIN and at location effective 8/23/2019.  DCannon"]
["Richard E Winn, MD",1073672994,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1255584397","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-08-26","1255584397","","2020-06-25",""]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.  DCannon"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-10-02","1255584397","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","Pending Info/Document","2023-01-09","","","2023-06-05","6/5/2023-Invalid CAQH Login-kavello"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-09-01","1255584397","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26","1255584397","","2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is enrolled - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2019-07-01","P02326890","","2020-03-30","3/25/2020--Per online check, provider is now PAR effective 07/01/2019 with provider number P02326890. Attached welcome letter to payor line\ntisha rader"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2019-08-30","1255584397","830358685","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1255584397","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1255584397","","2020-07-02","7/2/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Terminated","Terminated","2021-03-31","1255584397","","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"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2020-06-29","1255584397","","2020-07-09","07/09/2020 - Rec'd welcome letter stating this provider is PAR with Amerigroup STAR, STAR PLUS & Star Kids products through Texas True Choice - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-02-19","408008701","","2020-04-07","04/07/2020 - Rec'd letter from the payer stating this provider has been approved with TRADITIONAL medicaid only. - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-01","1255584397","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer (Irma from First Care) that this provider is EFF as of 7/1/2019 and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2019-06-01","1255584397","","2020-11-02","11/2/2020 - Moved to completed status after reviewing follow up note - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2019-07-01","833803","519061","2020-02-20","02/20/2020 - Updated information with EFF letter rec'd from Medicare - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.  DCannon"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-08-06","1255584397","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-06-23","5186048","","2021-07-27","7/27/2021 Received an email from PDMnotification@cigna.com with confirmation of approval for participation effective 6/23/2021 with assigned provider ID 5186048. KFrazier"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2011-07-29","1255584397","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-08-26","1255584397","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-03-13","14530139","","2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1528619525","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","403199901","079837301","2020-01-29","01/29/2020 - Found provider through payer portal. Provider is par with Traditional Medicaid only - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1528619525","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-07-01","6345073","","2020-07-10","07/10/2020 - Rec'd EFF email from the payer stating \"Welcome to the provider network effective 7/1/2020. Your Provider Identification Number (PIN) is: 6345073\" - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1528619525","","2020-10-01","10/01/2020 - Rec'd an email from the payer stating this enrollment has been completed  - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1528619525","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-12-11","1528619525","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312274","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Sent email to LeNetrice Myart for a roster for the PriMed delegation agreement.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-10-01","869041","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-10-01","1528619525","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1528619525","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-01-01","09832854","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-01","1528619525","","2020-07-27","IMS complete"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-01","1528619525","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-04-01","1528619525","","2020-09-24","09/24/2020 - moved to completed after reviewing follow up complete - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-12-13","1528619525","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 12-13-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-12-30","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 12/30/2019.  DCannon"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-12-11","13706552","","2020-07-21","07/21/2020 - Rec'd spreadsheet from the payer stating this provider/TIN/service location are PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated  - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-12-30","1528619525","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 12-30-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for Andrews Hwy., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for Andrews Hwy., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for the Eastridge location., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for the Eastridge location., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Longview location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Longview location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Briarwood location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Briarwood location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for Andrews Hwy., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for Andrews Hwy., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for the Eastridge location., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for the Eastridge location., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Longview location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Longview location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Briarwood location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Briarwood location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for Andrews Hwy., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for Andrews Hwy., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for the Eastridge location., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for the Eastridge location., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Longview location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Longview location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Briarwood location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Briarwood location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for Andrews Hwy., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for Andrews Hwy., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for the Eastridge location., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Tricare is unable to validate the address for the Eastridge location., therefore I am unable to enroll this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Longview location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Longview location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Briarwood location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-02","Application to add provider to the Briarwood location has been submitted. Process is taking up to 30 days. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Follow Up","","","","2023-09-13","Replied with requested information along with request of approx. processing time for the update. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Follow Up","","","","2023-09-13","Replied with requested information along with request of approx. processing time for the update. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Follow Up","","","","2023-09-13","Replied with requested information along with request of approx. processing time for the update. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Follow Up","","","","2023-09-13","Replied with requested information along with request of approx. processing time for the update. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Follow Up","","","","2023-09-13","Replied with requested information along with request of approx. processing time for the update. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Follow Up","","","","2023-09-13","Replied with requested information along with request of approx. processing time for the update. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Follow Up","","","","2023-09-13","Replied with requested information along with request of approx. processing time for the update. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Follow Up","","","","2023-09-13","Replied with requested information along with request of approx. processing time for the update. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-08-31",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-08-31",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-08-31",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-08-31",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-08-31",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-08-31",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-08-31",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-08-31",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44880,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44785,"","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder for provider to sign. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder for provider to sign. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder for provider to sign. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder for provider to sign. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder for provider to sign. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder for provider to sign. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder for provider to sign. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder for provider to sign. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Roster emailed to Karina Garcia at Corvel to add provider to TIN/locations. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Roster emailed to Karina Garcia at Corvel to add provider to TIN/locations. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Roster emailed to Karina Garcia at Corvel to add provider to TIN/locations. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Roster emailed to Karina Garcia at Corvel to add provider to TIN/locations. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Roster emailed to Karina Garcia at Corvel to add provider to TIN/locations. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Roster emailed to Karina Garcia at Corvel to add provider to TIN/locations. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Roster emailed to Karina Garcia at Corvel to add provider to TIN/locations. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Roster emailed to Karina Garcia at Corvel to add provider to TIN/locations. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-12","Added locations and COI, re-attested. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 9/12/2022.   MPIN# 008193055.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","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,"","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","",45184,"9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","",45184,"9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","",45184,"9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","",45184,"9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Multiplan enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Multiplan enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Multiplan enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Multiplan enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Multiplan enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Multiplan enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Multiplan enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Multiplan enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28","1922658319","","2022-10-24","10/24/2022 Rcvd TMHP approval letter.  Provider is PAR and linked to group effective 8/28/2022.  TPI # 1922658319.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","",45184,"9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","",45184,"9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44995,"8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44995,"8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44995,"8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44995,"8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44995,"8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44995,"8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44995,"8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44995,"8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10","8909854","","2023-03-13","3/13/2023 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 3/10/2023.  PID# 8909854 DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to Texas Mutual. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to Texas Mutual. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to Texas Mutual. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to Texas Mutual. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to Texas Mutual. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to Texas Mutual. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to Texas Mutual. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-15","Emailed TSCA and required documents to Texas Mutual. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-01","See status updates under Alliance WC payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-01","See status updates under Alliance WC payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-01","See status updates under Alliance WC payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-01","See status updates under Alliance WC payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-01","See status updates under Alliance WC payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-01","See status updates under Alliance WC payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-01","See status updates under Alliance WC payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-01","See status updates under Alliance WC payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-05","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-05","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-05","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-05","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-05","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-05","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-05","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-05","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44785,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH",44784,"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,"","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","",45170,"09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","",45170,"09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","",45170,"09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44816,"","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-01","09/01/2023.  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"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-10-13","13747034","","2020-12-23","12/23/2020 - Confirmed with HealthSmart that provider has been loaded effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312370","","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"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-12-01","","","2020-12-07","12/7/21020 - Rcvd confirmation email from Superior that provider has been loaded effective 12/1/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01","403920802","","2021-01-20","1/20/2021 Upon review of the TMHP portal, provider has been approved and issued TPI 403920802 under Group Tax ID/TPI. KFrazier"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-10-15","","","2020-11-20","11/20/20 - Rcvd confirmation email from UHC confirming enrollment at this location.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-01","","","2020-10-09","10/9/2020 Confirmed provider is certified as a non-network provider with TriCare East. Kimberly Frazier"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-12","","","2021-03-18","3/18/2021 Received email from BSWHPEXPEDITES@BSWHealth.org confirming provider has been approved and is participating under group effective 3/12/3021. KFrazier"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2021-12-01","3873524","","2022-03-23","3/23/2022 Per follow-up note - 03.10.2022.S/W Lania of Boon Chapman @ 800-950-7040. Provider NPI# is on file  and is participating effective 12/1/2021 under the group and TIN #. Provider ID#3873524.  Physical location is on file.Call ref# 7943427.- DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2020-03-31","1366762874","","2020-04-30","04/30/2020 - Signed into MMH group enrollment and found this provider is linked to the group at this serivce location EFF 3-31-2020. - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2013-11-01","9477656","","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 11/1/2019 , the physical location is on file and the Provider ID is 9477656.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-06-05","6/5/2023 - CAQH Reattested by Data Services Team - kavello"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Multiplan","Participating","Enrollment Complete","2020-02-10","1366762874","West Texas Physicians Alliance","2020-07-08","07/08/2020 - Rec'd email from the payer stating this provider is EFF: \"Thank you for contacting our Customer Service Department at Multiplan/PHCS. At this time we show that Olufemi Aduroja is currently participating with the Multiplan, PHCS, and BeechStreet networks. The participation is through West Texas Physicians Alliance.\n\nEffective Dates:\nMultiplan-01/08/2020\nPHCS- 02/10/2020\nBeechStreet-02/10/2020\" - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1366762874","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-02-10","1366762874","","2020-10-05","Enrolled thru PHCS"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Medicaid","Participating","Enrollment Complete","2025-03-16","386007403","364596201","2020-08-13","8/13/2020 - signed onto TMHP and confirmed this provider is EFF and affilaited with the group - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-05-04","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/4/2020.  DCannon"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-01-24","937962","0008AH","2020-03-04","03/04/2020 - rec'd welcome letter from the payer stating APPROVED eff 1-24-2020 and linked to group PTAN 0008AH - Stacey Hudak"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-11","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating under Group Tax ID and correct location effective 6/11/2020. Kimberly Frazier"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1306827266","","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"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","First Health Coventry","Participating","Enrollment Complete","","","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","In Process","Payor Follow Up","","","","2023-08-25","08.25.2023 S/W Mica of Cigna @ 1-800-882-4462. Per rep, provider is out of network. Application received on 07/13/2023 and still in process. Tracking# 13388358. No additional documents needed. TAT for processing is 90-120 calendar days. Call ref# MicaT08252023. - Willie Ravas"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2022-12-19","","","2023-02-28","2/28/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete",44914,"","","2023-03-09","3/9/2023 Per email rcvd from Karen Avalos at Galaxy, January monthly roster has been completed.  Provider is PAR and linked to group effective 12/19/2022.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2020-07-24","1302718","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 7/24/2020.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2020-02-11","P02476693","DU5783","2020-07-20","07/20/2020 - downloaded and attached welcome letter - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-06-05","6/5/2023 - CAQH Reattested by Data Services - kavello"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2014-11-01","P01415478","CE1588","2020-03-25","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2014 with provider number P01415478. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2014-02-05","1198630","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 2/5/2014.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-04-19","12080988","","2023-04-19","4/19/2023 CAQH reviewed and re-attested.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-22","","","2021-03-31","3/31/2021 Confirmed provider certified via Humana-Military portal effective 10/22/2020.  DCannon"]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-04-25","1922008234","","2020-06-05","06/05/2016 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Cindy Marriner, FNP",1922008234,"75-2656723: S","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1922008234","","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"]
["Cindy Marriner, FNP",1922008234,"75-2656723: P","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2014-12-01","1922008234","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-08","","","2022-02-10","12/10/2022 Per Tricare portal, provider is linked to location as of 12.8.2021. Cbankston"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2018-02-28","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/28/2018.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete",43910,"","",44532,"12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 3/20/2020.   DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","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","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","3961479","","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 3961479. KFrazier"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","2020-06-11","14085237","","2020-06-11","06/11/2020 - Provider did not supply CAQH login. Provider will maintain this info in-house - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2018-04-21","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is certified as non-network under group Tax ID and location effective 4/21/2018. Kimberly Frazier"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","595054YM2M","00304W","2020-09-22","9/22/2020 - rec'd email from the clinic stating this service location has been approved by the group medicaid enrollment - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2018-08-01","3169156","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2018 PID # 3169156-tisha rader"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-09-01","","","2020-11-10","11/10/2020 - Ref # 5554765 Rcvd email from UHC demo update completed MPIN # 006790663."]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","2022-11-15","Provider did not select inclusion with this payor."]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-05-23","13574654","","2022-03-23","03/23/2022 Per follow-up note - S/W Asia of Boon Chapman @ 800-950-7040. Provider NPI# is on file  and is participating effective 5/23/2017 under the group and TIN#. Provider ID# 13574654.Physical location is on file.Call ref# 7943427.-DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-07-06","1547832","","2020-07-07","07/07/2020 - Rec'd email from the payer stating \"Your effective date is 07/06/2020. Your provider identification number is 1547832. \" - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2017-03-01","1447701602","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2017-01-31","1447701602","","2020-06-04","06/24/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2017-01-31","1447701602","","2020-08-20","08/20/2020 - Rec'd spreadsheet from the payer confirming this provider is affiliated with PRIMED DELEGATION under this TIN/Service LOcation. THis provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete",44348,"","","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 Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","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."]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - 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 Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete",44341,"","","2021-09-14","9/14/2021 Per Tricare Portal provider is certified with TaxID as of 5/25/2021. Cbankston"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2016-07-26","","","2022-07-01","7/1/2022 Provider is PAR and linked to group TIN/location effective 7/26/2016.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2015-09-29","","","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 9/29/2015.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2018-08-03","1154767234","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) has sent confirmation that this provider is EFF with Amerigroup - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-08-30","1154767234","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2015-11-01","1154767234","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2017-01-01","1154767234","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2015-08-29","1154767234","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: S","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2015-10-07","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 10/7/2015.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: P","TX","PE - 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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685: T","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-02-20","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 2/20/2019.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-09","","","2022-03-09","3/9/2022 Per Tricare portal, provider is certified and linked to location as of 12/9/2021. Cbankston"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-09","","","2022-03-09","3/9/2022 Per Tricare portal, provider is certified and linked to location as of 12/9/2021. Cbankston"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2019-06-05","13355149","","2022-02-24","2/24/2022 Per follow-up note from 2/17/2022 -  NPI# for the provider is on file and shows Linked and Par under group and TIN# effective 6/5/2019, the physical location is on file and the Provider ID is 13355149.  Case ref#7918618.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2019-02-01"," 2327745","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 2/1/2019 PID # 2327745\ntisha rader"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/12021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment",43466,"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","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","758005","00304W","2020-09-22","09/22/2020 - Rec'd confirmation from the clinic that this service location has been approved under the group enrollment - stacey hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","2990326","","2020-11-30","11/30/2020 - Rcvd confirmation email from payer stating that provider has been linked and added to tax ID and location effective 12/1/2019.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-02-03","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","6609675","","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 # 6609675 DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1205299922","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider/location has been added to delegation - Stacey Hudak"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 3/20/2020.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-03","8/3/2021 Medicaid enrollment is done in-house by MCHS.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-08-01","","","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"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-29","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-10","7269406","","2020-09-03","09/03/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-03-20","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 3/20/2020.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.   DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-08-03","9835482","","2020-08-04","8/4/2020 - Rec'd email from the payer stating \"Your effective date is 08/03/2020. Your provider identification number is 9835482. \" - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1184265050","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-08-01","1184265050","","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"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-09-01","1184265050","","2020-09-10","09/10/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Sep 3, 2020 8:23:15 AM. Your request was assigned reference number PR-5475288 .\"  - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-08-01","","","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"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","9835482","","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 9835482. KFrazier"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Gallagher","In House Enrollment","In House Enrollment","","","","2022-09-15","9/15/2022 Enrollment is now done in-house by Ventra Health for Midland Emergency Managers effective 8/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","IMS","Participating","Enrollment Complete","2022-06-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","Multiplan","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"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748: S","TX","PE - Midland Medicine 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."]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine 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."]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748: S","TX","PE - Midland Medicine PA","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Boon Chapman","Participating","Enrollment Complete","2021-08-13","","","2021-09-15","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","HealthSmart PPO","Participating","Enrollment Complete","2021-08-09","","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/9/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","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"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748: S","TX","PE - Midland Medicine PA","Superior","Participating","Enrollment Complete","2021-09-01","","","2021-10-06","10/6/2021 Rcvd email from Superior that monthly delegation roster for August/September is complete and providers are loaded under TIN/locations effective 9/1/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - 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","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete",43709,"6167866","","2020-06-29","06/29/2020 - Rec'd email from the payer stating \"Thank you for your submission. This is to confirm that your request has been completed. \n \nPID # 6167866\nHCP Name #  Hagos Aymut\nTIN # 475554737\nEffective Date # 09/01/2019\nCigna Internal Reference # W202006161088488\" - Stacey Hudak"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete",45108,"","","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","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete",43709,"1922548890","","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"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2020-03-20","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 3/20/2020.  DCannon"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-09-16","414194701","364596201","2020-09-24","09/24/2020 - Signed into TMHP site and verified that this provider has been approved and added to the group - Stacey Hudak"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete",44102,"","","2021-01-14","1/14/2021 - Rcvd email from payer that provider is participating and loaded under tax ID effective 9/28/2020.  DCannon"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1750539268","","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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-07-24","5/1/2023 Add new locations - 4705 Briarwood Ave, 6950 Eastridge Rd.  and 6301 Andrews Hwy.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2018-11-30","1528430865","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, 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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",43495,"1528430865","",44062,"8/19/2020 - Rec'd a spreadsheet from the payer to confirm this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-27","7/27/2023 Rcvd email confirmation from Cigna that this group and Tax ID 47-3465832 are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the providers do not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2018-11-30","1271900","","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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to UHC to check status of August delegated roster provider loads.  PR-7623698.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-05-15","5/15/2023 Pending UHC enrollment.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2020-04-15","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 4/15/2020. Kfrazier"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-08-23","08.23.2023: Called Sedgwick (Through USA MCO) @ 1-800-625-6588. Waited on line for 44 minutes but still no rep available. Verification request has been emailed  to sedgwick@sedgwick.com to verify provider credentialing status.-Danico Gabriel Melendres"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-11-20","","","2020-09-14",""]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Facility Enrollment","","","","2020-10-05","10/5/2020 - this is a facility contact for urgent care. No provider credentialing/enrollment needed - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2018-12-15","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 12/15/2018.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-11","Provider is already participating. Emailed request to add additional location to wwtxcontracts@texasmutual.com. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","2020-04-15","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 4/15/2020. Kfrazier"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2018-11-30","1528430865","473465832",44062,"Confirmed provider is particpating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2018-10-01","715814","423838","2020-07-10","07/10/2020 - was granted access to group PECOS. Able to verify that this provider and service location are active. - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to Multiplan to check status of August delegated roster provider loads.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document",45135,"","","2023-07-27","Tricare isn't recognizing the Andrews Hwy location as a valid address, so I am unable to submit the application. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document",45135,"","","2023-07-27","Tricare isn't recognizing the Andrews Hwy location as a valid address, so I am unable to submit the application. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-27","Tricare isn't recognizing the Eastridge location as a valid address, so I am unable to submit the application. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2018-11-28","","","2021-05-06","5/6/2021  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 11/28/2018.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Facility Enrollment","","","","2020-10-05","10/5/2020 - this is a facility contact for urgent care. No provider credentialing/enrollment needed - Stacey Hudak"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2020-06-10","1215575576","","2020-09-08","09/08/2020 - Rec'd email from the payer confirming this provider is EFF:\n\"Network: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nJordan Elizabeth Friday, NP NPI: 1215575576\n5026 – West Texas Physicians Alliance – Beech St Eff Date 05/06/2020\n23655 – West Texas Physicians Alliance – MPI Eff Date 06/10/2020\n52669 – West Texas Physicians Alliance – PHCS Eff Date 06/10/2020\" - Stacey Hudak"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2020-08-01","1215575576","","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"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2023-06-05","14594087","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - 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","PE - Satish Nayak","Aetna","Participating","Enrollment Complete","2021-07-06","5595574","","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 7/6/2021.  PID # 5595574 DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - 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","PE - ADA Adult and Children Family Clinic LLC","Sedgwick","In Process","Pending Contracting","","","","2023-09-11","Per Debbie Mason at Sedgwick ADA Adult and Children Family Clinic is not in contract. Emailed group contract and agreement to Priscilla and Neeraja on 9/11/2023. Jen Videan"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","ADA Adult and Children Family Clinic LLC","Aetna","Participating","Enrollment Complete","2020-08-01","1922328079","","2020-09-22","9/22/2020 Provider is PAR and linked to group effective 8/1/2020."]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","ADA Adult and Children Family Clinic LLC","Wellcare","Participating","Pending Other Enrollment",44501,"","","2023-06-20","6/20/2023  Pending delegated roster submitted to Superior to add new location via group delegated roster.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Wellmed","Participating","Application Submitted","2022-01-01","","","2023-06-20","6/20/2023  Pending delegated roster submitted to UHC to add new location via group delegated roster.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","ADA Adult and Children Family Clinic LLC","Amerigroup","Participating","Enrollment Complete","2019-09-18","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 9/18/2019.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-06-14",""]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete",44117,"","",44267,"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"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-10-01","1538571609","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the PriMed delegation - Stacey Hudak"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2020-09-13","7196467","","2020-11-20","11/20/2020 - Rcvd email from UHC confirming enrollment status.  Provider is participating effective 9/13/2020, provider # 7196467."]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-08-05","1538571609","","2020-09-16","09/16/2020- Rec'd spreadsheet from the payer confirming this provider/service location have been made effective under the primed roster - Stacey Hudak"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2020-08-24","Q00083402","DU5783","2021-06-09","6/9/2021 Submitted on-line application and immediately received assigned RR PTAN, which is Q00083402 under group RR PTAN DU5783, effective 8/24/2020. KFrazier"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2019-12-13"," 9959784","","2020-06-26","06/26/2020 - moved to completed status after reviewing Follow Up Complete note - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2017-03-30","1225277833","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","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","PE - Andrews County Hospital District","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Texas Mutual","Participating","Enrollment Complete","2023-05-01","","","2023-05-10","5/10/2023 Rcvd TX Mutual - WorkWell approval letter.  Provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2017-03-22","1225277833","","2020-07-01","07/01/2020 - Rec'd confirmation email from the payer stating this provider is EFF - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete",45128,"","","2023-08-15","Per Michelle Killough @ PSWCA Dr. Molina is par effective 07/21/2023. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2017-04-03","1225277833","263789190","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - 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","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2017-03-22","1225277833","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-11","Emailed roster to Karina Garcia at Corvel. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Gallagher","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2016-07-19","442715YTA9","0A3812","2020-09-25","09/25/2020 - Rec'd email from this clinic that this provider is EFF with Medicare - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","In Process","Pending Info/Document","","","","2023-09-11","Emailed Sedgwick forms to Priscilla and Neeraja for Dr. Tochterman to sign and complete . Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Zurich","Panel Closed","Panel Closed","","","","2023-07-24"," 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"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete",43770,"6163991","","2020-08-18","8/18/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2016-10-26","1972942209","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 10/26/2016.  DCannon"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2016-10-26","1972942209","751997880","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","","RHC PART A ONLY","","2020-07-28","07/28/2020 - THIS SERVICE LOCATION AND GROUP NPI IS FOR AN RHC FACILITY (part A) only. \n\nThere is no provider link/reassignment for this group.\n\nThis provider is active with Medicare, but cannot be reassigned to this TIN/Group NPI. It bills under facility only, not by provider.  Moved to completed status to remove from work list - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2017-06-05","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 6/5/2017.  DCannon"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - 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","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2020-08-05","04727805","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received a roster from Amerigroup confirming that provider is PAR and linked to group TIN/location effective 8/5/2020.  DCannon"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete",42894,"1083867147","263789190",44062,"Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1083867147","","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"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2017-10-23","1083867147","","2020-07-15","07/15/2020 - Rec'd email from the payer stating this provider is already affiliated with the PRIMED DELEGATED AGREEMENT and enrolled with this group TIN/Service Location and group NPI# 1124054069 - Stacey Hudak\n\n**Verified this provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Hartford","Panel Closed","Panel Closed","","","","2023-07-25","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"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - 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,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-13","11/14/22 Per Scarlett Abigail, TIN has active 400TX DCN.  TIN has association of RHC."]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete",44091,"","",44179,"12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Texas Mutual","Participating","Enrollment Complete",45108,"","",44438,"8/30/2021 Email received from mgorman@texasmutual.com, Drs. Fitzgerald and Hada-Ondriezek were presented to the Committee two weeks ago and approved for participation in our network.  Both will “go live” with the network on September 1st. Cbankston"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2019-08-30","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","2019-05-03","","","2021-12-27","12/27/2021 Received email form michelle.killough@pswca.org, provider has been active with Tax ID  75-1997880 since 05/03/2019. Cbankston"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete",44562,"","","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, DNP",1669617981,"26-3789190","TX","PE - 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"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2015-06-23","1669617981","","2020-09-23","09/23/2020 - Confirmed via self-service portal, provider is certified as non-network provider under group Tax ID. KFrazier"]
["Jennifer B Hada-Ondriezek, DNP",1669617981,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2020-09-17","","","2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1972073906","","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"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2023-07-01","","","2023-08-10","Confirmed active via online portal. MS"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2020-07-14","","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/14/2020.  DCannon"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete",44440,"","","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"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete",43709,"1184626749","","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"]
["Peggy Thurston, NP",1205941564,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete",44025,"","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 7/13/2020.  DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-10","","","2023-05-10","5/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-04-12","","","2021-11-03","11/3/2021 Per follow-up notes.  Provider NPI# is on file for the provider and is participating effective 04/12/2021 under the group and TIN#.   Physical location is on file. Call ref# 14226636.  DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2014-05-15","","","2020-09-14",""]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - 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","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete",44048,"","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-02","","","2020-08-20","08/20/2020 - Rec'd spreadsheet back from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT Under this TIN/Service Location. Provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","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","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2021-01-12","","","2021-03-08","3/8/2021 Rcvd confirmation from Cigna that provider is now participating under TIN and linked to location effective 1/12/2021.  CPID # 8214651.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician 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"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2023-04-19","","","2023-04-19","4/19/2023 CAQH reviewed and re-attested.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1184035313","","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"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1184035313","","2020-08-21",""]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2020-07-17","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Wellcare","Participating","Enrollment Complete",44501,"","","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,"75-1997880","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1306928098","","2020-08-21",""]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","Liberty Mutual","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Aetna","Participating","Enrollment Complete","2016-04-01","1306928098","","2020-07-20","07/20/2020 - moved to completed status after reviewing Follow up Complete note. This provider has a DIRECT contract - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2011-11-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 11/01/2011.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","TriCare Standard","Participating","Enrollment Complete","1996-12-03","","","2020-10-23","10/23/2020 Upon review of the self-service portal, provider is certified as a non-network provider, as well as participating under group with location. Kimberly Frazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1306928098","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","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,"75-1997880","TX","","Medicare","Facility Enrollment","Facility Enrollment","","RHC GROUP NPI - Part A Only","","2020-07-28","RHC ENROLLMENT ONLY - Part A Only - Facility enrollment only. No providers can be linked to this enrollment.  \n\nMoved to enrollment complete to remove from worklist - 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","","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","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-07-14","03829159","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","Zurich","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","Zurich","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/4/2021 Provider does not see WC patients; therefore, enrollment has stopped. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Sedgwick","Participating","Enrollment Complete","2016-03-16","1161265","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 03/16/2016.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2021-11-18","","","2021-12-14","12/14/2021 Per tircare portal provider linked to location as of 11/18/2021. Cbankston"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1184626749","","2020-08-21",""]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - 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"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2018-03-01","1184626749","","2020-07-30","7/30/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Participating","Enrollment Complete",41512,"138408315","324676101","2020-10-23","10/23/2020 - moved to completed status after receiving a copy of the approved medicaid letter - Stacey Hudak"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","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.\""]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","Cigna","Participating","Enrollment Complete","2021-02-02","1181373","","2021-02-22","2/17/2021 - Rcvd confirmation email from CIGNA that provider is participating effective 2/2/2021 PIN 1181373.  DCannon"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","Medicaid","Participating","Enrollment Complete",44126,"145611901","079837301","2020-10-27","10/27/2020 - rec'd an email from the clinic stating this provider is effective with this payer. - Stacey Hudak"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete",41821,"26229118","","2023-05-02","5/2/2023 Per confirm par status note - Per rep, provider is showing participating with an effective date 07/01/2014 and link under the Group and TIN. Provider ID 26229118. 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#:610334.  DCannon"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2013-11-01","","","2020-12-24","12/24/2020 Provider is certified as non-network provider under Group Tax ID and location. KFrazier"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - 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"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-12-14","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/14/2020.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-12","8/12/2021 Per email received from Candace Wynne, she has submitted an application to add provider to location via the TMHP portal. KFrazier"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-11-08","","","2021-11-30","11/30/21 Per Tricare portal, provider added to location. Cbankston"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-12-14","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/14/2020.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","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","PE - Premier Family Care, Inc","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"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44091,"","","2020-11-12","11/12/20 - Received email from payer 10/20/20 that provider has been loaded in their system as a participating provider effective 9/17/20.  DCannon"]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312232","","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"]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-06-01","6615260","","2021-07-08","7/1/2021-S/W Jessie of AETNA @ 8003531232, NPI# of the provider is on file and shows link and PAR under the group and TIN# effective 6/1/2021, physical location is on file. Provider ID is 6615260.  As per Rep, Rep confirmed that once provider is credentialed w/ Aetna automatically, provider is also credentialed w/First Health and Coventry. Call ref#6028231587."]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",44146,"7533626","","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 11/11/2020 and assigned provider ID 7533626. KFrazier"]
["Rachel Murphy, RD",1124637160,"75-2656723","TX","PE - 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 Murphy, RD",1124637160,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Provider Type Not Enrolled","Provider Type Not Enrolled","","","","2021-09-07","9/7/2021 Rcvd email from LaNetrice Myart @ USA PPO that registered dieticians are not credentialed/enrolled through USA PPO.  There fore enrollment will be stopped for this provider.  DCannon"]
["Eliana Kelley, NP",1184278251,"75-1997880","TX","","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Eliana Kelley, NP",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","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"]
["Eliana Kelley, NP",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-07","1291204","","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"]
["Eliana Kelley, NP",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2021-01-28","","","2021-08-07","7/14/2021 Received email response from networkhelp@uhc.com stating provider is participating under group Tax ID effective 1/28/2021. KFrazier"]
["Julie Parker, NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-10-09","10/9/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 1/7/2021.  DCannon"]
["Julie Parker, NP",1720538606,"75-1997880","TX","PE - 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, NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete",44203,"1310979","","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"]
["Julie Parker, NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-06-01","","","2022-10-06","10/6/2022 Per email from Vernita Young at Humana provider is PAR and linked to group TIN/locations effective 6/1/2022.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2022-06-01","3330657","","2022-10-31","10/31/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 6/1/2022.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.   DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Enrollment Stopped","Enrollment Stopped","","","","2023-08-17","8/17/2023 Per notification from MQA provider is no longer w/ MCHS effective 7/14/2023.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-06-01","","","2022-10-10","10/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2022.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-06-01","","","2022-10-10","10/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2022.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-06-01","","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 6/1/2022.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","",44862,"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"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Enrollment Stopped","Enrollment Stopped","","","","2023-08-17","8/17/2023 Per notification from MQA provider is no longer w/ MCHS effective 7/14/2023.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-09-01","6761851","","2022-10-18","10/18/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN effective 9/1/2022.  PID # 6761851.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-09-01","6761851","","2022-10-18","10/18/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN effective 9/1/2022.  PID # 6761851.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-09-01","","","2023-01-24","1/24/2023 Rcvd email from Priscilla Albertine at MQA of confirmation that provider is PAR in Superior Health plan under the group TIN effective 9/1/2022.   DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.   MPIN# 007808995.   DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete",44713,"","","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 6/1/2022.   MPIN# 007808995.   DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-10-01","","","2023-01-19","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 10/1/2022. Location is on file. Provider ID is 3546319. Next recredentialing date is every 3 years (10/1/2025) No information for the payer#. -Kim Monique Fabian"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2014-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine at MQA she spoke w/ Shakita H. at Ambetter 800-218-7453 and provider is PAR and linked to group TIN and 3 MCHS locations - 801 E. Florida, 401 E. Illinois and 4214 Andrews Hwy effective 1/14/2014.  Ref # I-66177590.  Requested written confirmation of 4th address - 400 Rosalind Redfern Grover Pkwy.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-06-01","","","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 6/1/2022.   DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-06-01","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 6/1/2022.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2022-06-01","","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 6/1/2022.  DCannon"]
["Rami Bonam, MD",1821384058,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2021-02-17","4936231","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 2/17/2021 and assigned provider ID 4936231. KFrazier"]
["Rami Bonam, MD",1821384058,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2021-02-01","","","2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Rami Bonam, MD",1821384058,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-01-07","","","2021-02-02","2/2/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Rami Bonam, MD",1821384058,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2021-03-26","","","2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Pending Info/Document","","","","2023-09-13","CAQH password invalid. Unable to add locations. Emailed Priscilla and Neeraja for CAQH password assist. Jen Videan"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2021-11-18","","","2022-05-20","05/19/2022 Per follow-up note on 2/6/2022 - Received email from wwtxcontracts@texasmutual.com that provider is in network.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2021-03-26","","","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 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-03","9/3/20023 Coventry panel closed at this time.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-03","9/3/2023 Coventry panel closed at this time.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-03-26","","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 3/26/2021. DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-03-31","2032079","","2021-04-19","4/19/2021 Received email from PDMCOGZ@cign.com with confirmation provider has been loaded under Tax ID with both locations effective 3/31/2021 with assigned provider ID 2032079. KFrazier"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-03","9/3/2023 Coventry panel closed at this time.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-03","9/3/2023 Coventry panel closed at this time.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-03-31","5225969","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 3/31/2021 and assigned provider ID 5225969. KFrazier"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Submitted roster to Karina Garcia at Corvel to add to TIN and locations. Jen Videan"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023. 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"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-03-26","","","2021-06-03","6/1/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/10/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2021-03-26","","","2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",44281,"","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 3/26/2021. DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-03-26","","",45176,"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 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-03-26","6518709","","2021-07-01","7/1/2021 Per Aetna roster received from Jamie Roberts provider is PAR and linked to TIN/locations effective 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-12","Submitted application via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-12","Submitted application via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Provider Load","Action Needed","","","","2023-09-03","9/3/2023 Add to new locations - 6301 Andrews Hwy,  4705 Briarwood Ave. and  6950 Eastridge Rd.   DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-03",""]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","",45159,"8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Pending Info/Document","","","","2023-09-13","CAQH password invalid. Unable to add locations. Emailed Priscilla and Neeraja for CAQH password assist. Jen Videan"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2021-03-26","","","2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 3/26/2021.  DCannon"]
["Paula Kaye Brookings, NP",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-04-13","4/13/2021 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, enrollment and approval are required with BCBS of TX before may enroll for VACCN network participation, which are all processed In-House.  Kfrazier"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Aetna","Participating","Enrollment Complete","2021-01-07","","","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 Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 1/7/2021.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 1/7/2021.  DCannon"]
["Meagan Leighann Cunningham, FNP",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 01/07/2021.  DCannon"]
["Meagan Leighann Cunningham, FNP",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2021-01-07","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 1/7/2021.  DCannon"]
["Meagan Leighann Cunningham, FNP",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete",44203,"","",44314,"4/28/2021 Rcvd delegated roster from S&W with provider listed as PAR and linked to TIN and location.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-12","","","2021-03-16","3/16/2021 Received an email from BSWHPEXPEDITES@BSWHealth.org confirming approval of participation under group Tax ID and location with an effective date of 3/12/2021. However, they state to allow 3-4 weeks before submitting claims to allow sufficient time for loading into their system. KFrazier"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete",44235,"","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 2/8/2021.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2021-02-08","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/8/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-02-08","","","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 02/08/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2021-03-15","","","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 3/15/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2022-03-31","","","2022-04-13","4/13/2022 Per Tricare portal, provider is certified and linked to location as of 3.31.2022. Cbankston"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2021-03-15","","","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 3/15/2021.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","","","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2023-01-01","","","2023-01-24","1/24/2023 Rcvd email from Priscilla Albertine at MQA of confirmation that provider is PAR in Superior Health plan under the group TIN effective 1/1/2023.   DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-12-15","12/15/2022 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"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2021-04-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 4/1/2021.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","No Enrollment Required","No Enrollment Required","2021-04-02","","","2022-04-01","No enrollment required due to this being a RHC. DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2021-04-15","6529979","","2021-07-01","7/1/2021 Per Aetna roster received from Jamie Roberts provider is PAR and linked to TIN/locations effective 4/15/2021.  DCannon"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2022-12-01","2M8579","0A3812","2022-12-28","12/28/2022 Rcvd copy of Medicare approval letter.  Provider is PAR and linked to group effective 12/1/2022.  PTAN # 2M8579.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Omni PPO","Participating","Enrollment Complete","2021-04-06","","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 4/6/2021. DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete",44348,"","","2021-12-03","12/3/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2022-03-02","","","2023-02-28","2/28/2023 Per email received from Priscilla Albertine at MQA provider is PAR with Molina and linked to group effective 3/2/2022.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-05-28","5155848","","2021-07-09","7/1/2021- S/W Ana of Cigna @  8008824462, NPI# is on file for the provider,shows link and Par  under the group and TIN# effective 5/28/2021 the physical location is on file.  Provider ID is 5155848, No call ref#- Herminia Gilongos"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-05-20","","","2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 5/20/2021.  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-10-13","10/13/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-15","6626989","","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 6/15/2021.  PID # 6626989  DCannon"]
["Lisa A. Hernandez, NP",1942766092,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2021-04-15","4/15/2021 Denisse Villa maintains provider CAQH profiles. However, requested via email to confirm provider is current re-attestation and pending response. KFrazier"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2021-06-08","426493901","364596201","2021-09-09","9/9/2021 Rcvd TMHP Approval letter from Candace Wynne.  TPI # 426493901 - effective 6/8/2021 DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2021-05-10","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/10/2021.  DCannon"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-05-10","","","2021-06-03","6/3/2021 Rcvd email from Galaxy Health, Karen Avalos <kavalos@ghn.mci.com> that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-05-10","","","2021-06-03","6/1/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-07-04","0396521","","2021-07-06","6/24/2021 Received email from discovercigna@information.cigna.com confirming provider is participating under group Tax ID effective 7/4/2021 with assigned provider ID 0396521. KFrazier"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-05-10","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2021-05-10","","","2021-06-03","6/3/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 6/1/2021.  DCannon"]
["Kristin M Moose, FNP",1215213970,"75-2182177","TX","PE - Debbie P. Reese, 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."]
["Kristin M Moose, FNP",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Boon Chapman","Participating","Enrollment Complete","2021-06-10","","","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 6/10/2021.  DCannon"]
["Kristin M Moose, FNP",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Amerigroup","Participating","Enrollment Complete","2021-06-10","","","2021-11-11","11/11/2021 Rcvd email from Marco Rodriguez @ Amerigroup confirming that provider is PAR under group TIN/location effective 6/10/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832: S","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-07-01","1R4342","423838","2021-07-13","7/13/2021 Received approval notice from payor with assigned provider PTAN 1R4342 effective 7/1/2021, under group PTAN 423838. KFrazier"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - 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","PE - 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","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Thru Other Payor","2021-08-13","","","2021-09-16","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-08-28","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832: S","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2021-10-08","","","2021-12-02","12/2/21 Received email from michelle.killough@pswca.org, provider eff 10/08/2021 with Tax ID 75-2656723. Cbankston"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Provider Load","Provider Load","","","","2023-09-02","9/2/2023 Add locations - 4705 Briarwood, 6950 Eastridge Rd and 6301 Andrews Hwy.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832: S","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Confirm Par Status","","","","2023-09-05","Need to submit application to add additional locations under same TIN. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Confirm Par Status","","","","2023-09-05","Need to submit application to add additional locations under same TIN. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832: S","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-07-19","","","2021-09-08","9/8/2021 Per email received from Rep Karen Deal at karen.deal@cigna.com confirming group is contracted as an ancillary facility and not enrollment is required, and all claims are paid under the group. KFrazier"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",45047,"","","2023-09-01","9/1/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832: S","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Action Needed","","","","2023-08-23","08.23.2023 S/W TinM of Cigna @ 1-800-882-4462. Per rep, provider is out of network. No application found. Per rep, for office base provider the application process would be over the phone. TAT of 90-120 calendar days. Hospital base provider, application process would be via email through intake_pdm@cigna.com indicating the following information: prov name, social, dob, specialty, degree, tax id, name of the group, service and mailing address, effective date and copy of a W9 form. TAT of 20-30 calendar days. Call ref# TinM08232023. - Willie Ravas"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to Scott & White to check status of August delegated roster provider loads.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-05","09/05/2023. 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"]
["Jeffery Dickson, NP",1851865067,"47-3465832: T","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-07-01","Q00126646","DX4335","2021-09-03","9/3/2021 Upon application submitted, received assigned RR PTAN Q00126646 effective 7/1/2021 under group RR PTAN DX4335. KFrazier"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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: S","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-08-13","","","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 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Provider Load","Provider Load","","","","2023-09-01","9/1/2023 Add location - 6301 Andrews Hwy.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-09-01","3642314","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 9/1/2021.  PID #3642314.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-08-13","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832: S","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2021-08-13","","","2021-09-16","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832: S","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2021-08-13","","","2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 8/13/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832: T","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-07-10","","","2021-07-13","7/13/2021 Received email confirmation from Rep Angela.Matesevac@wpsic.com confirming provider has now been loaded under group Tax ID and location effective 7/10/2021. KFrazier"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","Multiplan","Participating","Enrollment Complete","2021-08-13","","","2021-09-15","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","Caprock (CapStar)","Participating","Enrollment Complete","2021-08-13","","","2021-10-06","10/6/2021 Rcvd email from CapRock that monthly delegated roster has been loaded and the provider is PAR and linked to group TIN/location effective 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","USA PPO","Participating","Enrollment Complete",44421,"","","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 8/13/2021.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","BCBSTX","Participating","Enrollment Complete","2023-06-08","","","","06/08/2023 - effective date. Participating with the following products: Blue Advantage HMO, BlueChoice PPO, Health Select, Blue Essentials, Medicare Advantage HMO, Medicare Advantage PPO, Dual Eligible Special Needs Plan, Wellmed MA HMO\n-PA"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-03-24",""]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","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"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","First Health Coventry","In Process","Action Needed","","","","2023-09-02","There was no status selected, and per the 1st health site, she is not enrolled. Just wanted to bring this to your attention. MS."]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Medicare","Participating","Enrollment Complete",44440,"1U3424","1T8900","2021-09-25","9/25/2021 Per PECOS provider is PAR and linked to group/locations.  PTAN # 1U3424 - effective 9/1/2021.  DCannon"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","TriCare Standard","Participating","Enrollment Complete","2021-12-15","","","2022-02-10","2/10/2022 Per tricare portal, provider is linked to location as of 12/15/2021. Cbankston"]
["Adrienne C Do, PA",1003372418,"85-3162122","TX","PE - Basin Dermatology","Omni PPO","Participating","Enrollment Complete","2021-08-26","","","2021-10-22","10/22/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for September has been completed and updated in their system effective 8/26/2021.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete",44518,"","","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"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-08-01","","","2023-07-11","7/11/2023Received confirmation from Client that provider is PAR and linked to delegate effective 8/1/2022. MS"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-06-01","","","2023-07-19","7/19/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-07-12","Q00306920","CE1588","2022-08-11","8/11/2022 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # Q00306920 - effective 7/12/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-01","","","2022-10-28","10/28/2022 Per follow-up note from 10.25.2022 S/W Daria of Amerigroup @ 800-454-3730. Provider is on file and participating. Link under the group and TIN effective 8/1/2022. Location is on file. Provider ID is 14349218. No recredentialing date provided. DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-06","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/6/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-11-01","","","2021-12-30","12/30/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 11/1/2021.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2022-04-05","","","2022-04-21","4/21/2022 Per email received from Ryan Gardner at Multiplan provider is PAR and linked to group/location effective 4/5/2022.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete",44501,"","","2022-09-15","9/15/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","In Process","Application Submitted","","","","2023-09-19","9/19/2023 Emailed demographic updated letter and W-9 to pdsdallas@aetna.com to add provider to group TIN/location.  DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2021-10-29","","","2022-03-11","3/11/2022 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 10/29/2021.  DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-10-29","","","2021-12-12","12/12/2021 Sent f/u email to Michelle Monroe at Galaxy to check status of November Delegated Roster load.  Per email response November Delegated Roster load has been completed and provider is PAR w/ group/location effective 10/29/2021.  DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2021-11-18","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 11/18/2021.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-10-12","0056401","","2021-10-28","10/28/2021 Per follow-up notes.  Provider NPI# is on file for the provider and is participating effective 10/12/2021 under the group and TIN#. PIN 0056401. Physical location is on file. Call ref# Roberts10272021. DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2021-12-01","6014588","","2022-02-24","02/24/2022 Per follow-up note from 2/17/2022 Provider NPI# is on file for the provider and is participating effective 12/01/21 under the group and TIN#. PIN 6014588. Physical location is on file. Ref# 6075311576. DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","1780693648","1851764963","2023-01-24","1/24/2023 Per TMHP web portal provider is PAR and linked to group effective 11/7/2007.  TPI # 1780693648.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2022-01-15","","","2022-01-24","1/24/2022 Rcvd approval letter, provider is PAR and linked to group/location effective 1/15/2022.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2022-01-10","002937778","","2022-05-11","5/11/2022 Received email confirmation that provider is PAR and linked to group TIN/location effective 1/10/2022.  MPIN# 002937778.  DCannon"]
["Brandon H Rayne",1912482209,"","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Provider Load","Provider Load","","","","2023-08-24",""]
["Brandon H Rayne",1912482209,"","TX","PE - Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-08-29","Emailed roster to Karina Garcia. Jen Videan"]
["Brandon H Rayne",1912482209,"","TX","PE - Urgent Orthopedic Specialists, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-28","08/28/2023. 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"]
["Brandon H Rayne",1912482209,"","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","In Process","Application Submitted","","","","2023-09-01","Per Michelle Killough at pswca no record of provider. Need to apply. Submitted application via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-11","Emailed roster to Karina Garcia at Corvel. Jen Videan"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","In Process","Pending Info/Document","","","","2023-09-11","Emailed Sedgwick forms to Priscilla and Neeraja for Dr. Sastry to sign and complete . Jen Videan"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-07-25","See Alliance WC payor line status. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-15","","","2022-06-22","6/22/2022 Per phone conversation with Jennifer Penn at Scott & White provider is PAR and linked to group TIN/location effective 6/15/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - 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","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2021-12-01","0570215","","2022-04-06","4/6/2022 Received email from pdmcogz@cigna.com, provider is eff and linked to group as of 12/1/2021. PID 0570215. Cbankston"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - 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"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-03-04","2E5656","0008AH","2022-06-13","6/13/2022 Rcvd Medicare approval letter.  PTAN # 2E5656 - effective 3/4/2022.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-04-08","","","2022-09-16","9/16/2022 Received approval letter from Scott & White.  Provider is PAR and linked to group TIN/location effective 4/8/2022.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-05-09","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/9/2022.  DCannon"]
["Joshuae G Gallardo, MD",1689985962,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",43313,"1689985962","1275522864","2022-07-14","7/14/2022 Per TMHP web portal provider is PAR and linked to group effective 8/1/2018.  TPI # 1689985962.  DCannon"]
["Joshuae G Gallardo, MD",1689985962,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete",44682,"","","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."]
["Joshuae G Gallardo, MD",1689985962,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-02-01","Q00267329","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267329 - effective 2/1/2022.  DCannon"]
["Joshuae G Gallardo, MD",1689985962,"75-2656723","TX","PE - 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.\""]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44687,"","","2022-05-19","5/19/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 5/6/2022.  DCannon"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - 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"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-03-02","","","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 3/2/2022. DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-02-15","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 2/15/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Provider Load","Action Needed","","","","2023-09-04","9/4/2023 Add to new locations - 6301 Andrews Hwy,  4705 Briarwood Ave. and  6950 Eastridge Rd.   DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Provider Load","Action Needed","","","","2023-09-04","9/4/2023 Add to new locations - 6301 Andrews Hwy,  4705 Briarwood Ave. and  6950 Eastridge Rd.   DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-05-17","","","2023-05-17","received approval letter from Careworks effective 5/17/2023. MS."]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-02-04","","","2022-03-09","3/9/2022 Rcvd email from German Aviles confirming that February delegated roster has been completed and providers are loaded in IMS/Omni effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-05","See status updates under Alliance WC payor line. Jen Videan"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-07-20","07/18/2023. 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"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023 Coventry panel is closed at this time.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-02-04","","","2022-07-07","7/7/2022 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 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",44596,"","","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 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-04-16","","","2022-04-15","Received email from networkhelp@uhc.com, enrollment is complete and eff 4.16.2022. MPIN 7967451. Cbankston"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-04-15","","","2022-04-22","4/22/2022 Rcvd approval letter from payor effective 4/15/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45047,"","","2023-09-12","CAQH reviewed and re-attested. Jen Videan"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",44596,"","","2022-04-19","4/19/2022 Per email from VThomas at Humana provider is PAR and linked to group TIN/location effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Roster submitted.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",44667,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 4/16/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","","","","2023-09-08","Provider is enrolled with all locations under WesTex MS"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-10-01","3627806","","2023-01-19","01.19.2023 S/W Kurtney of First Health @ 800-226-5116. Per rep, provider is showing participating with an Effective date 10/01/2022 and link under the Group and TIN. Provider ID 3627806, Payer ID 73159 and Recredentialing date 10/01/2025. Service location is on file. Call ref#:517681. -Danico Gabriel Melendres"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-12","Submitted application via pswca.org. Jen Videan"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-08-22","8/22/2023 Sent follow-up email to Marcus Wester at Humana to check status of May monthly delegated roster submission.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-02-04","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-03-15","","","2022-07-14","7/14/2022 Per email received on 5/5/2022 from Scott & White delegation roster provider load has been completed.  Providers are PAR and linked to group/locations effective 3/15/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023 Coventry panel closed at this time."]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-02-04","","","2022-03-25","3/25/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-02-04","1334000","","2022-08-23","08/23/2022 - Per follow-up note - Per email response received from Corvel Healthcare Corp on 08/17/2022. Provider NPI# is on file active and par under the TIN and Group effective 02/04/2022. Physical location is on file. Provider ID 1334000.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",44632,"2E9362","423838","2022-06-22","6/22/2022 Rcvd Medicare approval letter.  PTAN# 2E9362 - effective 3/12/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","",45175,"Submitted roster to add additional locations to Karina Garcia at Corvel. Jen Videan"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023 Coventry panel closed at this time.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-03-12","Q00315729","DX4335","2022-08-26","8/26/2022 Rcvd Rail Road Medicare  approval letter.  PTAN # Q00315729 - effective 3/12/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-04",""]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2022-02-04","","","2022-03-09","3/9/2022 Rcvd email from German Aviles confirming that February delegated roster has been completed and providers are loaded in IMS/Omni effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",44607,"6299165","","2022-03-23","3/23/2022 Per follow-up note - DM: Called Aetna @ 800-353-1232 to obtain FU status for  the provider and Spoke to Alvin. Per rep, NPI# is on file for the provider and is Participating Effective 02/15/2022 under the group and TIN#. Physical location is on file. Provider ID is 6299165. Call ref#:6080313797. -DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-02-03","2.3.23 Plan pends enrollment with Coventry WC. ABoles"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",44596,"","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",44596,"","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023. 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"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-04-15","","","2022-04-22","4/22/2022 Rcvd approval letter from payor effective 4/15/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-10-01","3627806","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 10/1/2022.  PID #3627806.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",44596,"","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-05","9/5/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Enrollment on Hold","Enrollment on Hold","","","","2023-09-13","6301 Andrew Hwy Midland, TX 79706 is a new location, therefore, a site visit needs to be completed by Texas Mutual. Jen Videan"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",44774,"","","2022-08-04","8/4/2022 Received approval letter for TX Mutual/Workwell.  Provider is PAR effective 8/1/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Pending Info/Document","","","","2023-09-13","Need updated Sedgwick forms signed by provider. Emailed request to Priscilla and Neeraja. Jen Videan"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-02-04","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2022-02-04","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/4/2022.  DCannon"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-20","07/18/2023. 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"]
["Shawn Collins Harris, NP",1679236053,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Ambetter","Participating","Enrollment Complete",44713,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 6/1/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","First Health Coventry","Participating","Enrollment Complete",44690," 3558017","","2022-07-28","7/28/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","TriCare Standard","Participating","Enrollment Complete",44813,"","","2022-09-15","9/15/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 9/9/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Wellmed","Participating","Enrollment Complete","2022-08-27","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/27/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Omni PPO","Participating","Enrollment Complete",44690,"","","2022-07-07","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Omni PPO","Participating","Enrollment Complete",44690,"","","2022-07-07","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2023-03-09","3/9/2023 Per email from LaNetrice Myart at USA PPO provider is PAR and linked to group/location effective 5/9/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Enrollment Stopped","Enrollment Stopped","","","","2022-09-22","9/22/2022 Per Candace Wynne provider is not practicing under MIMA TIN.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-13","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/13/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2022-05-01","2E5418","519061","2022-06-10","6/10/2022 Rcvd Medicare approval letter.  PTAN# 2E5418 - effective 5/1/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44805,"","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",44743,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 7/1/2022.   DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-07-01","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 7/1/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-08-16","8/16/2023 CAQH reviewed added new practice location and re-attested.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45175,"","","2023-09-19","Received completion email. Eff 9/6/2023 MS"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2022-08-05","6284348","","2022-08-23","8.20.2022 -Per follow-up note provider is PAR and linked to group TIN# effective 8/5/2022, the physical location is on file and the Provider ID is  6284348.   DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-18",""]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete",44690,"","","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"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-06-02","6/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-09-06","9/6/2022 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"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-05-09","","","2022-08-20","8/20/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2022-05-09","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-05-09","3558012","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/9/2022.  PID# 3558012  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2022-05-09","3558012","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/9/2022.  PID# 3558012  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-26",""]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-26",""]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-10-28","10/28/2022 Per Tricare/Humana Military is currently not accepting requests to join the medical surgical network. Will check back soon to see if we are accepting network providers.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-07-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/24/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-05-09","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-06-29","","","2022-07-14","7/14/2022 Per Humana Military provider portal provider is PAR and linked to group TIN/location effective 6/29/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-06-29","","","2022-07-14","7/14/2022 Per Humana Military provider portal provider is PAR and linked to group TIN/location effective 6/29/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete",44690,"","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","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","PE - 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","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-05-09","6689991","","2022-06-21","6/21/2022 Per follow-up note - S/w Joan of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 05/09/2022  under the group and TIN#. PIN: 6689991. Physical location is on file. Call ref# 6094998732. - DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete",44713,"","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-06-05","6/5/2023 - CAQH Reattested by Data Services - kavello"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-06-20","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 6/20/2022.   DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Rail Road Medicare","Participating","Enrollment Complete",44682,"P02660539","EB8061","2022-09-16","9/16/2022 Rcvd RR Medicare approval letter.  PTAN # P02660539 - effective 5/1/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","HealthSmart PPO","Participating","Enrollment Complete",44732,"","",45118,"Received confirmation from Client. MS"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","TriCare Standard","Participating","Enrollment Complete",44764,"","","2023-09-01","Confirmed via Tricare web portal. MS"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Medicaid","Pending Other Enrollment","Pending Medicare","","","","2022-06-22",""]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete",44835,"","","2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-12-17","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 12/17/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44788,"","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/15/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-08","","","2023-05-08","5/8/2023 CAQH re-attested by provider.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2022-08-15","Q00322555","CD1588","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322555 - effective 8/15/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete",44816,"","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for September is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-06-20","","","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 6/20/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2022-09-22","","","2022-10-04","10/4/2022 Rcvd Tricare approval letter stating that provider is now a Tricare-certified provider in Texas effective 9/22/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-06-20","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 6/20/2022.   DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-06-20","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-12-01","","","2022-12-02","12.02.2022 S/W Aaron of Aetna @ 800-353-1232. Per rep, provider is showing participating with an Effective date 12/01/2022 and link under the Group and TIN. Provider ID 6799298, Payer ID 60054 and Recredentialing date 11/18/2025. Service location is on file. Call ref#:6122321344. - Danico Gabriel Melendres\\"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","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"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44760,"Q00299482","CE1588","2022-07-28","7/28/2022 Rcvd RR Medicare approval letter.  PTAN # Q00299482 - effective 7/18/2022.  DCannon"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-03","","","2023-03-06","3/6/2023 Rcvd approval email from Cigna.  Provider is PAR and linked to group/location effective 3/3/2023.  PID# 5538089.  DCannon"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Add Info Submitted","","","","2023-09-19","Submitted requested information. MS"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"Q00328215","CE1588","2022-09-16","9/16/2022 Rcvd RR Medicare approval letter.  PTAN # Q00328215 - effective 8/28/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Medicaid","Pending Other Enrollment","Pending Medicare","","","","2022-09-08",""]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","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"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","United Health Care","Participating","Enrollment Complete",44802,"006795726","","2022-10-27","10/27/2022 Rcvd email from UCH that provider load has been completed and provider is PAR and linked to group TIN/location effective 8/29/2022.  MPIN # 006795726.   DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Cigna","Participating","Enrollment Complete",44847,"","","2022-11-29","11/29/2022 Rcvd email from Cigna at intake_pdm@cigna.com that provider is PAR and linked to group TIN/location effective 10/13/2022.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44966,"3357467","","2023-02-16","02.16.2023  Per follow-up note - S/W Stephanie of Cigna @ 1-800-882-4462. Per rep, provider is showing participating with an Effective date 02/09/2023 and link under the Group and TIN. Provider ID 3357467, No Payer ID and Recredentialing date 02/09/2026. Service location is on file.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",44816,"","","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 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",44816,"","","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 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",44816,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6410739 DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",44816,"","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",44866,"3637702","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID #3637702.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",44866,"3637702","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/1/2022.  PID #3637702.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",44816,"","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-10-01","2J7030","423838","2022-10-10","10/10/2022 Rcvd Medicare approval letter.  PTAN # 2J7030 - effective 10/1/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 5/1/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to Scott & White to check status of August delegated roster provider loads.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Submitted roster to Karina Garcia at Corvel to add additional locations. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",44816,"","","2023-04-28","4/28/2023 Rcvd email from Priscilla Albertine at MQA that she received from Joe Rodriguez at Amerigroup that the provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Provider Load","Action Needed","","","","2023-09-04","9/4/2023 Add to new locations - 6301 Andrews Hwy,  4705 Briarwood Ave. and  6950 Eastridge Rd.   DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",44816,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-08-22","","","2023-08-22","8/22/23- CAQH Reattested, added 3 practice locations and updated COI- kavello"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2022-09-12","","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete",45047,"","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 5/1/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-12","Emailed application and required documents to spneast@sedgwickcms.com to add additional locations. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-08-23","08.23.2023: Called Sedgwick (Through USA MCO) @ 1-800-625-6588. Waited on line for 44 minutes but still no rep available. Verification request has been emailed  to sedgwick@sedgwick.com to verify provider credentialing status.-Danico Gabriel Melendres"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-15","","","2022-10-10","10/10/2022 Per roster received from Scott & White provider is PAR and linked to TIN effective 10/15/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to Multiplan to check status of August delegated roster provider loads.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-08-02",""]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-08-02",""]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",44866,"3637702","","2023-01-31","01.31.2023 S/W Brenda of First Health @ 800-226-5116. Per rep, provider is showing participating with an Effective date 11/01/2022 and link under the Group and TIN. Provider ID 3637702, No Payer ID and Recredentialing date 11/01/2025. Service location is on file. Call ref#:530216. -Danico Gabriel Melendres"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Enrollment on Hold","Enrollment on Hold","","","","2023-09-12","Per Dee Dee Johnson at Texas Mutual since 6301 Andrews Hwy is a new location a site visit will need to be completed before it can be added. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",44932,"","","2023-01-17","1/17/2023 Rcvd PSWCA/Alliance approval letter.  Provider is PAR and linked to group TIN effective 1/6/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023 Coventry panel closed at this time.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-03-10","6410739","","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# 6410739 DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-05-01","","","2023-05-10","5/10/2023 Rcvd TX Mutual - WorkWell approval letter.  Provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-12","Submitted application via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Pending Other Enrollment","","","","2023-09-04","9/4/2023 Pending enrollment w/ Alliance workers comp.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-04",""]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete",44816,"","","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 9/12/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-22","Enrollment Panel is Closed. MS"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Roster submitted.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-04","9/4/2023 Coventry panel closed at this time.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44816,"008299480","","2022-11-01","11/1/2022 Rcvd email from UCH that provider load has been completed and provider is PAR and linked to group TIN/location effective 9/12/2022.  MPIN # 008299480.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45047,"","","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"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",44833,"","","2022-10-28","10/28/2022 Per Tricare/Humana Military portal provider is PAR and linked to group TIN/location effective 9/29/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","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"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",44835,"","","2022-10-26","10/26/2022 Rcvd Rail Road Medicare approval letter.  PTAN # Q00353706 - effective 10/1/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",44835,"","","2022-10-26","10/26/2022 Rcvd Rail Road Medicare approval letter.  PTAN # Q00353706 - effective 10/1/2022.  DCannon"]
["Ramon Lujan, NP",1205572716,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",44816,"6785892","","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 09/12/2022. PIN: 6785892. Physical location is on file. No next recredentialing date available. Payer# 60054. Call ref# 6163704296. - Willie Ravas"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","Participating","Enrollment Complete","2022-08-31","1972946648","","2022-09-14","9/14/2022 Per email from Denisse Villa at MCHS provider is PAR in TX Medicaid effective 8/31/2022.  TPI # 1972946648.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","DO NOT ENROLL","","","","2022-11-18","Provider Type Not Applicable"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete",44802,"","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete",44802,"","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete",44802,"","","2022-11-04","11.04.2022 Per follow-up note - S/W Chealse of Amerigroup @ 800-454-3730. Per rep, provider is showing participating with an  Effective date 08/29/2022 and link under the Group and TIN. Provider ID 14501240, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-166745338.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete",44866,"","","2023-02-15","02.15.2023 S/W Shannon of First Health @800-226-5116. Per rep, provider is in network and linked under the TIN effective 11/01/2022. Don't have next recredentialing date. Provider ID# 1972946648. Physical location is on file. Don't have payer#. Unable to obtain call ref# since rep transferred me to a different department. - Mary Rose Acebedo"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete",44802,"8664296","","2022-10-18","10/18/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN effective 8/29/2022.  PID # 8664296.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete",44802,"8664296","","2022-10-18","10/18/2022 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN effective 8/29/2022.  PID # 8664296.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-08-29","007265245","","2022-10-24","10/24/2022 Received confirmation email from UHC that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2022-08-29","007265245","","2022-10-24","10/24/2022 Received confirmation email from UHC that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-08-29","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete",44802,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for September is complete.  Provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete",44802,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete",44802,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete",44835,"","","2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete",44835,"","","2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-15","","","2022-10-10","10/10/2022 Per roster received from Scott & White provider is PAR and linked to TIN effective 10/15/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete",44802,"","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete",44802,"","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete",44760,"9246114","","2022-10-26","10/26/2022 Rcvd email from CIGNA that provider is PAR and linked to group TIN/locations effective 7/18/2022.  PID # 9246114.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete",44812,"","","2022-09-15","9/15/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 9/8/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete",44802,"","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete",44802,"","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete",44835,"","","2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44866,"Q00346338","CE1588","2022-10-15","10/15/2022 Rcvd RR Medicare approval letter.  PTAN # Q00346338 - effective 11/1/2022.  DCannon"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete",44866,"","","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"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44866,"","","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"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44844,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 10/10/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2022-09-26","","","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 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-09-26","","","2023-05-02","05.02.2023  Per follow-up note - S/W Marina of Corvel Healthcare Corp @ 800-872-0820. Per rep, provider is showing PAR and link under the Group and Tax ID with an Effective date 09/26/2022. Provider ID 1341506, Recredentialing date is 09/26/2025. Service location is on file. Call ref#:Marina05022023.-Danico Gabriel Melendres"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-07-11","Updates under Alliance WC Plan. MS"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician 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"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete",44866,"","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","","","","2022-09-06","9/6/2022 This TIN is an RHC and therefore individual providers cannot be linked to group.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",44893,"","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 11/28/2022.   DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44893,"","","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 11/28/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44893,"","","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"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44958,"","","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"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete",44865,"","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from November has been completed and provider is PAR effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete",44896,"","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete",44865,"","","2022-12-29","12/29/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete",44896,"","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete",44896,"","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2022-10-31","","","2023-02-25","2/25/2023 Per email received from Vernita Young November delegated roster has been processed and provider is PAR effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete",44865,"","","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","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete",44865,"","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete",44865,"","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete",44865,"","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-24","Tricare Prime panel is closed. MS"]
["Taylor Allison Arrington",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Superior","Participating","Enrollment Complete",44986,"","","2023-03-10","3/10/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 3/1/2023.  DCannon"]
["Taylor Allison Arrington",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","USA PPO","Participating","Enrollment Complete",44963,"","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Taylor Allison Arrington",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Omni PPO","Participating","Enrollment Complete",44963,"1558971432","","2023-07-19","7/19/2023 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for February has been completed.  Provider is PAR and linked to group effective 2/6/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2023-05-24","2Y7249","","2023-09-06","Received confirmation letter. MS"]
["KristiAnne Alexis Gore, PA-C",1558971432,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Ambetter","Participating","Enrollment Complete","2023-03-01","1558971432","","2023-03-10","3/10/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 3/1/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2023-02-06","1558971432","","2023-07-19","7/19/2023 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for February has been completed.  Provider is PAR and linked to group effective 2/6/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2023-02-06","1558971432","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 2/6/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","In Process","Payor Receipt Validated","","","","2023-09-12","Received email from Cigna rep stating that they have received the request to participate and have forwarded the request to Cigna Texas Network Management for processing. BID 13387960 MS"]
["KristiAnne Alexis Gore, PA-C",1558971432,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45000,"1558971432","","2023-08-22","8/22/2023 Per email from Scott & White provider is PAR and linked to group TIN/location effective 3/15/2023.  DCannon"]
["KristiAnne Alexis Gore, PA-C",1558971432,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","CAQH","Participating","CAQH Reattested",45138,"15745440","","2023-07-31","7/31/23- updated CAQH with 5424 19th street location and reattested -kavello"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Confirm Par Status","","","","2023-09-15","I am waiting on the 855I to be completed for providers other group enrollment. Once he is issued a PTAN, I will complete an 855R to add to WesTex at that time. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Confirm Par Status","","","","2023-09-15","I am waiting on the 855I to be completed for providers other group enrollment. Once he is issued a PTAN, I will complete an 855R to add to WesTex at that time. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"84-2617748","TX","PE - Midland Medicine PA","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-09-06","Still Pending Medicare enrollment. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Provider Load","Provider Load","","","","2023-09-07",""]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","In Process","Pending Medicare","","","","2023-09-07",""]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"84-2617748","TX","PE - Midland Medicine PA","USA PPO","Participating","Enrollment Complete",45078,"","","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 6/1/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"84-2617748","TX","PE - Midland Medicine PA","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-07","9/7/2023 Pending Multiplan enrollment.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Zurich","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Cigna","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Hartford","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-07",""]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-07",""]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"84-2617748","TX","PE - Midland Medicine PA","Cigna","In Process","CAQH Reattested","","","","2023-09-15","The CAQH needed to be reattested for the payer to pull for processing. This was added to my monthly invoice. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Provider Load","Provider Load","","","","2023-09-07","9/7/2023 Add to WesTex Urgent Care TIN/locations.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","United Health Care","Participating","Enrollment Complete",45078,"2419969","","2023-07-20","7/20/2023 Rcvd email confirmation that provider is PAR and linked to group effective 6/1/2023.  MPIN# 2419969.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Ambetter","Participating","Enrollment Complete",45139,"","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","CAQH","Participating","CAQH Reattested",45035,"","","2023-04-19","4/19/2023 CAQH reviewed and re-attested.  Update practice location information, credentialing contacts and employment information.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete",45127,"","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Boon Chapman","Participating","Enrollment Complete",45078,"","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","First Health Coventry","Participating","Enrollment Complete",45078,"","","2023-07-26","07.27.2023 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 06/01/2023. Provider ID 1910887. Service location is on file. Call ref#:709557. - Danico Gabriel Melendres"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Wellmed","Participating","Enrollment Complete",45078,"","","2023-07-26","7/26/2023 Per email received from UHC provider is PAR and linked to group/TIN effective 6/1/2023.  DCannon"]
["Jose A Suarez, MD",1669470332,"27-4061759","TX","","Superior","Participating","Enrollment Complete",45139,"","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-08-24","See status updates under Alliance WC payor line. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","","","","2023-09-14","Added practice locations and re-attested. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","","","","2023-09-14","Added practice locations and re-attested. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-08-28","Application submitted via pswca.org website. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",45047,"","","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","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Roster submitted.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Stephanie R Powell, PA-C",1538714076,"","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Roster submitted.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45047,"","","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","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Application Submitted","","","","2023-08-31","Request to add Longview and Andrews Hwy locations submitted to Intake_pdm. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-15",""]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",45201,"","","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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-09-01","Application submitted to add provider to Briarwood location.  Process can take 30 days. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-14","Emailed TSCA and required documents to spneast@sedgwickcms.com requesting to add additional locations to provider's profile. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-14","Emailed TSCA and required documents to spneast@sedgwickcms.com requesting to add additional locations to provider's profile. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",45016,"3671302","","2023-09-01","9/1/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 3/31/2023.  PID # 3671302.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",45047,"","","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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-08-15","8/15/2023 Pending UHC enrollment.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45060,"","","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,"","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Enrollment Complete","","","","2023-09-06","Rcvd approval letter from Karina Garcia. Effective 08/21/2023 for 210 W Longview, 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-03-17","2V9975","","2023-08-25","Per PECOS provider is PAR and linked to group/locations effective 3/17/2023.  PID # 2V9975.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2023-08-23","Roster emailed to Benjamin Richbourg.benjamin.richbourg@primehealthservices.com\nJen Videan"]
["Stephanie R Powell, PA-C",1538714076,"","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2023-08-23","Roster emailed to Benjamin Richbourg.benjamin.richbourg@primehealthservices.com\nJen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-14","Emailed TSCA to Texas Mutual requesting additional locations be added to provider's profile. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-14","Emailed TSCA to Texas Mutual requesting additional locations be added to provider's profile. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-08-01","","","2023-08-08","Rcvd approval letter. Effective 08/01/2023. Jen Videan"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-05-12","Alliance and TX Municipal are one in the same. Please see the Alliance payer line for status updates. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","","TriCare Standard","In Process","Enrollment Complete","2023-08-08","","","2023-08-23","Confirmation of the Briarwood location has been established effective 8/8/23. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-08-08","","","2023-08-08","6301 Andrews Hwy. location is unable to be validated, so Tricare will not all me to enroll this location. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-04-14","","","2023-07-20","7/20/2023 Per email received from Galaxy April  delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-04-14","","","2023-05-18","Cigna does not require individual enrollment for facility based contracts. Provider will be billing claims under the facility, not individually. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-04-14","","","2023-06-21","Rcvd effective date of 04/14/2023 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-04-14","","","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 4/14/2023.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2023-08-23","Roster emailed to Benjamin Richbourg.benjamin.richbourg@primehealthservices.com\nJen Videan"]
["Sabrena Marrero, NP",1518346428,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2023-08-23","Roster emailed to Benjamin Richbourg.benjamin.richbourg@primehealthservices.com\nJen Videan"]
["Sabrena Marrero, NP",1518346428,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-08","Submitted application via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Sabrena Marrero, NP",1518346428,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-03",""]
["Sabrena Marrero, NP",1518346428,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-12","Emailed add location request to wwtxcontracts@texasmutual.com. Jen Videan"]
["Sabrena Marrero, NP",1518346428,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-08-22","8/22/2023 Sent follow-up email to Marcus Wester at Humana to check status of May monthly delegated roster submission.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-08-11","See status updates under Alliance WC payor line. Jen Videan"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-04-14","","","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 4/14/2023.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",44988,"2W1114","423838",45124,"Received approval letter. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-03-03","","","2023-08-15","Provider is active with group, therefore all locations under the group, she will be considered enrolled as well. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-04-14","","","2023-09-05","9/5/2023 Per follow-up email from UHC provider is PAR and linked to group/location effective 4/14/2023. \n DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-05-24","Confirmed provider is added to all locations. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-05-10","Pending Coventry enrollment. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 5952597 DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-04-14","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 4/14/2023.  PID # 3671303.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","3671303","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  PID # 3671303.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-04-25","4/25/2023 Pending UHC enrollment.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-04-25","4/25/2023 Pending UHC enrollment.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-08","Submitted application via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-10","Per the representative at Travelers, the Coventry panel is closed, which also closes the panel for Travelers WC. Ref #12308451"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-08-21","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-25",""]
["Sabrena Marrero, NP",1518346428,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Payor Follow Up","","","","2023-09-19","09.19.2023 S/W Kris 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: 6712960. Physical location is on file but showing as out of network. No application found. To add/update location, we need to send LOI with the w9 form to fax# 8594558650. ATTN to Demographic Update. TAT for processing is 30 business days. Call ref# 6163714512. - Willie Ravas"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-16",""]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-04-14","","","2023-07-12","Received confirmation email from rep. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-04-14","","","2023-07-12","Received confirmation email from rep. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-05-15","Confirmed with rep that provider will need to be active with Coventry prior to submitting the request to join Gallagher. I've saved the enrollment instructions in the Gallagher file. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-05-01","","","2023-08-23","8/23/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-04-14","","","2023-09-01","9/1/2023 Per email from Marcus Wester at Humana April delegated roster has been completed and provider is PAR effective 4/14/2023.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-05-15","Pending Coventry enrollment. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-05-15","Pending Coventry enrollment. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-04-14","","","2023-07-20","7/20/2023 Per email from Jessica Bess at Multiplan provider is PAR  effective date of 04/14/2023.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-04-14","","","2023-05-19","Checked enrollment status via https://providersearch.usamco.com/wintprovsearch . Provider is enrolled with Group Health and Wellness PPO. MS"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2023-09-05","9/5/2023 Sent follow-email to UHC to check status of May delegated roster.  Reference: PR-7418966.  DCannon"]
["Sabrena Marrero, NP",1518346428,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2023-09-05","9/5/2023 Sent follow-email to UHC to check status of May delegated roster.  Reference: PR-7418966.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Roster submitted.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-03-03","Q00521328","DX4335","2023-07-27","7/27/2023 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group effective 3/3/2023. PID # Q00521328.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-05-10","Pending Coventry enrollment. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","",45061,"Confirmed with rep that provider will need to be active with Coventry prior to submitting the request to join Gallagher. I've saved the enrollment instructions in the Gallagher file. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-05-18","Pending Coventry enrollment. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-08","Submitted application via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Receipt Validated","","","","2023-09-18","Payor has confirmed receipt of the application and is in process. Reference number 13455414  MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-05-15","5/15/2023 Pending UHC enrollment.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-10","Per the representative at Travelers, the Coventry panel is closed, which also closes the panel for Travelers WC. Ref #12308451"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-05-10","Per the representative at Travelers, the Coventry panel is closed, which also closes the panel for Travelers WC. Ref #12308451"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Panel Closed","Panel Closed","","","","2023-05-24","Pending Coventry Enrollment. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",45047,"","","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"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-05-17","Pending enrollment approval for PWSA-Alliance WC. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - 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","PE - 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","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-05-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-19",""]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-19",""]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45047,"","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45047,"","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-05-18","Cigna does not require individual enrollment for facility based contracts. Provider will be billing claims under the facility, not individually. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-08-01","","","2023-07-31","07/31/2023, PA: Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO,  Medicare Advantage PPO and Health Select, effective 08/01/2023"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-08-01","","","2023-07-31","07/31/2023, PA: Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO,  Medicare Advantage PPO and Health Select, effective 08/01/2023"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-08-01","","","2023-08-08","Rcvd approval letter. Effective 08/01/2023. \nJen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Roster submitted.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-12-28","","","2023-05-12","Confirmed via the Humana Military portal Eff 12/28/2022. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-03-03","2W1107","423838","2023-07-17","Enrollment letter received. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-08-23","08.23.2023: Called Sedgwick (Through USA MCO) @ 1-800-625-6588. Waited on line for 44 minutes but still no rep available. Verification request has been emailed  to sedgwick@sedgwick.com to verify provider credentialing status.-Danico Gabriel Melendres"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",45047,"","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2023-09-05","9/5/2023 Sent follow-email to UHC to check status of May delegated roster.  Reference: PR-7418966.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-07-12","","","2023-07-12","Received email confirmation from Jacki Hipolito. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-08-01","8/1/2023 Pending UHC enrollment.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-12","Panel is currently closed."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-12","Panel is currently closed."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-05-01","","","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 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-05-18","Pending Coventry enrollment. MS"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","Enrollment on Hold","Pending Contracting","","","","2023-08-22","Per Benjamin Richbourg benjamin.richbourg@primehealthservices.com, Permian Physician Services is not contracted and needs a signed agreement and HCN addendum. Emailed agreement and addendum to Priscilla and Neeraja. Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-05-04","5/4/2023 Rcvd Tricare approval letter, provider is Tricare certified w/ group TIN effective 4/25/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2017-06-12","","","2023-06-01","6/01/2023 S/W Latuya of MultiPlan @ 1-800-950-7040.Per rep, Provider NPI# 1639251481 is on file for the provider and is participating, effective 6-12-2017 under the group and TIN# 26-3789190. PIN: 12424933. Physical location is on file. Next credentialing is not required. no payer ID. Call ref# 8813120. - Jherimiah Medina"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Molina","Provider Load","Pending Medicaid","","","","2023-07-10",""]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-08","","","2023-05-22","5/22/2023 Rcvd email from Caprock that May roster has been processed and provider is PAR w/ group effective 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-04-25","4/25/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Omni PPO","Participating","Enrollment Complete","2023-05-08","","","2023-07-19","7/19/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/8/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-24","7/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-05-24","Confirmed via the HM portal. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","","","",45160,"Application submitted via TMHP. Request ID: 20311123. Jen Videan"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-19",""]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-07-01","","","2023-07-24","7/24/2023 Rcvd email from Superior that provider is PAR and linked group via delegated roster effective 7/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-06-01","","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",45047,"","","2023-08-21","Confirmed enrollment. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2W8694","","2023-08-01","Received enrollment completed email effective 5/1/2023. \nApplication Tracking ID: T071820230002417\n NPI ID: 1083672778\n Medicare ID: 2W8694\n Name: DAVID HAYNIE\n State: TX\n Form Type: 855I\n Date: 08/01/2023\n Status: APPROVED"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2023-04-25","4/25/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","In Process","Payor Requested Additional Info","","","","2023-09-18","Payor requested hospital admitting priv. This has been sent back to them via email. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-20","","","2023-08-08","Per response from hpdelegation@bswhealth.org, Dr. Hayne is effective 07/20/2023. Jen Videan"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-06-01","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-06-01","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete",45047,"","","2023-08-16","Received email confirmation of approval for updated location. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-14","","","2023-08-31","8/31/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","4160673","","2023-08-04","8/4/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 4160673 DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-08-01","8219691","","2023-09-19","09.19.2023 S/W Kris of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 08/01/2023. PIN: 8219691. Physical locations are on file. Next recredentialing date is on 08/01/2026. Payer# 60054. Call ref# 6163714512. - Willie Ravas"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-08-08","","","2023-08-23","Confirmation the provider has been linked to the Briarwood and Longview locations. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-08-08","","","2023-08-23","Tricare is unable to validate the Andrews Hwy. location as a valid address, therefore is unable to enroll this location at this time. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2023-08-08","","","2023-08-23","Confirmation the provider has been linked to the Briarwood and Longview locations. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-08","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-08","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-08-04","8/4/2023 Pending UHC enrollment.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-08-04","8/4/2023 Pending UHC enrollment.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/locations effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/locations effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-09-19","Emailed Michelle Killough for status. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Monthly delegated roster submitted to Humana to add provider to delegated roster.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Monthly delegated roster submitted to Humana to add provider to delegated roster.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-07-19","See status updates under Alliance WC.          \nJen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-07-31","","","2023-09-06","Added practice locations and re-attested. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-08-01","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to UHC to check status of August delegated roster provider loads.  PR-7623698.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-08-01","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-08-18","Provider Information Roster emailed to Karina Garcia at Corvel. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-04-29","","","2023-08-22","Confirmed provider is linked to all group locations. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-01","Confirmed panel is closed. MS"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Monthly delegated roster submitted to USA PPO to add provider to delegated roster.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-08-11","See status updates under Alliance WC payor line. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Monthly delegated roster submitted to First Health to add provider to delegated roster.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Monthly delegated roster submitted to First Health to add provider to delegated roster.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2023-08-23","Roster emailed to Benjamin Richbourg.benjamin.richbourg@primehealthservices.com\nJen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Monthly delegated roster submitted to USA PPO to add provider to delegated roster.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to Multiplan to check status of August delegated roster provider loads.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-08-04","8/4/2023 Pending Multiplan enrollment.  DCannon"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-13","Emailed TSCA to Texas Mutual requesting additional locations to be added to provider's profile. Jen Videan"]
["Andrea Sanders Sanchez, NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-13","Emailed TSCA to Texas Mutual requesting additional locations to be added to provider's profile. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-08-23","Application for Longview location submitted. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-08-23","Tricare is unable to validate the Andrews Hwy location, therefore no enrollment can be completed. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-08-23","Tricare is unable to validate the Andrews Hwy location, therefore no enrollment can be completed. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-08-23","Tricare is unable to validate the Eastridge location, therefore no enrollment can be completed. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-08-23","Application for Longview location submitted. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-09-06","Still Pending Medicare. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-06-02","Pending Coventry Enrollment. MS\n 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 07/19/2023"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-08-24","See status updates under Alliance WC payor line. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-08-24","See status updates under Alliance WC payor line. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-08-28","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-08-28","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","In Process","See Other Payor Line","","","","2023-09-02","Please see other Medicare Payor line for updates. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","See Other Payor Line","","","","2023-09-02","Please see other Medicare Payor line for updates. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-23",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-09-07","Per Karina Garcia at Corvel submitted provider off to credentialing. She will reach out if anything else is needed. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2023-09-07","Per Karina Garcia at Corvel submitted provider off to credentialing. She will reach out if anything else is needed. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-24","08/24/2023. 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"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-12","Emailed location add request to wwtxcontracts@texasmutual.com. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-12","Application and required documents submitted to SPNEAST@sedgwickcms.com.\nJen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-04",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-04",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2023-08-23","Roster emailed to Benjamin Richbourg.benjamin.richbourg@primehealthservices.com\nJen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Facility Enrollment","","","","2023-09-13","Rep confirmed there is an ancillary contract in place. Ancillary provider are not required to be enrolled individually. Claims are bill through the group. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Multiplan enrollment.  Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-06-12","","","2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2023-06-05","13954674","","2023-06-05","6/5/2023- confirmed all provider information was correct, added 2 Midland locations and reattested- kavello"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to Scott & White to check status of August delegated roster provider loads.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","Thru Other Payor","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","PE - West Texas Allergy, PA","United Health Care","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to UHC to check status of August delegated roster provider loads.  PR-7623698.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Aetna","Participating","Enrollment Complete","2023-05-29","4523940","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 5/29/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete",45075,"Q00516460","CF8499","2023-07-19","7/19/2023 Rcvd RR Medicare approval letter.   PTAN # Q00516460 - effective 5/29/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Galaxy Health","Participating","Enrollment Complete","2023-08-01","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-07-19","7/19/2023 Pending UHC enrollment.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - 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","PE - West Texas Allergy, PA","Humana","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Monthly delegated roster submitted to Humana to add provider to delegated roster.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Panel Closed","Panel Closed","","","","2023-06-08",""]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Tricare Prime","Panel Closed","Panel Closed","","","","2023-07-10",""]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Omni PPO","Participating","Enrollment Complete",45139,"","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","CAQH","Provider Load","CAQH Reattested","2023-07-31","","","2023-07-31","7/31/23 - Confirmed all information is current and reattested- Kavello"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-10","Thru Coventry Health. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-07-25","7/25/2023 Pending Multiplan enrollment.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Zurich","Panel Closed","Panel Closed","","","","2023-07-10","Thru Coventry Health. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Superior","Participating","Enrollment Complete","2023-09-01","","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Humana","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Monthly delegated roster submitted to Humana to add provider to delegated roster.   DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Humana","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Monthly delegated roster submitted to Humana to add provider to delegated roster.   DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Cigna","In Process","Payor Follow Up","","","","2023-09-19","Payor confirmed application is complete and has been forwarded to credentialing for review. Reference number 13387410  MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Medicaid","In Process","Application Submitted","","","","2023-09-06","Application submitted TMHP website. Request: 20319844. Jen Videan"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","In Process","Application Submitted","","","","","9/15/2023 Delegated roster submitted.  DCannon"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-07-11","","","2023-07-11","7/11/2023- added all midland information and confirmed all other info was current and reattested-kavello"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","In Process","Pending Info/Document","","","","2023-09-07","Requested current driver's license for Dr. Kota from MQA required for Medicaid enrollment. Jen Videan"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45127,"","","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"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Humana","In Process","Payor Follow Up","","","","2023-09-01","9/1/2023 Sent follow-up email to Marcus Wester at Humana to check status of June monthly delegated roster submission.  DCannon"]
["Rahul P Sinha, MD",1598182412,"","TX","PE - Premier Family Care, Inc","Multiplan","In Process","Pending PSV","","","","2023-08-30",""]
["Rahul P Sinha, MD",1598182412,"","TX","","Scott&White (First Care)","In Process","Add Info Submitted","","","","2023-09-12","9/12/2023 Emailed requested additional information - Scott & White Provider Data form, hospital privilege form and W-9.   DCannon"]
["Rahul P Sinha, MD",1598182412,"","TX","PE - Premier Family Care, Inc","Omni PPO","In Process","Pending PSV","","","","2023-08-30",""]
["Rahul P Sinha, MD",1598182412,"","TX","PE - Premier Family Care, Inc","Humana","In Process","Pending PSV","","","","2023-08-30",""]
["Rahul P Sinha, MD",1598182412,"","TX","","Medicaid","Pending Other Enrollment","Pending Medicare","","","","2023-08-30",""]
["Rahul P Sinha, MD",1598182412,"","TX","PE - Premier Family Care, Inc","Aetna","In Process","Payor Follow Up","","","","2023-09-19","09.19.2023 S/W AbiR of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna but not for the state of TX and not linked to the group and TIN#. Application received on 09/02/2023 and is still in process. Rep advised to allow more time. Tracking# 34152804. No additional documents needed. TAT for processing is 30 business days. Call ref# 6163760835. - Willie Ravas"]
["Rahul P Sinha, MD",1598182412,"","TX","","USA PPO","In Process","Pending PSV","","","","2023-08-30",""]
["Rahul P Sinha, MD",1598182412,"","TX","PE - Premier Family Care, Inc","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2023-08-30","8/30/2023 Pending Superior enrollment.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-08-15",""]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-08-15","8/15/2023 Pending UHC enrollment.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-09-06","Still Pending Medicare. MS"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-07-10","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-08-18","Emailed Provider Information Roster to Karina Garcia at Corvel. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-07-10","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 7/10/2023.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","",45153,"8/15/2023 Monthly delegated roster submitted to Aetna to add provider to additional locations.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-07-10","","","2023-08-23","8/23/2023 Rcvd email from Galaxy that July roster has been processed and provider is PAR w/ group effective 7/10/2023.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to Multiplan to check status of August delegated roster provider loads.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete",45117,"","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2023-09-01","","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/locations effective 9/1/2023.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-08-15","8/15/2023 Pending Multiplan enrollment.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-10","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-13","Emailed TSCA to wwtxcontracts@texasmutua.com requesting to add additional locations. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","",45182,"Emailed TSCA to wwtxcontracts@texasmutua.com requesting to add additional locations. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","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. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","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. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","",45184,"9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","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",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","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",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In House Enrollment","In House Enrollment","","","","2023-08-15",""]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","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",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-08-17","Provider Data Form and required credentialing documents emailed to Michelle Killough at michelle.killough@pswca.org. 08172023 Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to UHC to check status of August delegated roster provider loads.  PR-7623698.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to UHC to check status of August delegated roster provider loads.  PR-7623698.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Monthly delegated roster submitted to First Health to add provider to additional locations.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Monthly delegated roster submitted to Humana to add provider to additional locations.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-07-12","Through Coventry Network. MS"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-16",""]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","See Other Payor Line","","","","2023-09-19","Notes are being made on the other Medicare payor lines. MS"]
["Taylor Brown",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-13","TSCA and required documents emailed to spneast@sedgwickcms.com to add additional locations. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-13","TSCA and required documents emailed to spneast@sedgwickcms.com to add additional locations. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Facility Enrollment","","","","2023-09-13","Rep confirmed there is an ancillary contract in place. Ancillary provider are not required to be enrolled individually. Claims are bill through the group. MS"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document",45154,"","","2023-08-16","Tricare will not validate the Andrews Hwy. location address, therefore the location cannot be added under the TIN. MS"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document",45154,"","","2023-08-16","Tricare will not validate the Andrews Hwy. location address, therefore the location cannot be added under the TIN. MS"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete",45154,"","","2023-08-23","Provider is linked with Briarwood and Longview locations effective 8/16. MS"]
["Taylor Brown",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document",45154,"","","2023-08-16","Tricare will not validate the Eastridge location address, therefore the location cannot be added under the TIN. MS"]
["Taylor Brown",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-08-16","Texas Municipal League is Alliance WC. Please see other payor line for updates. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-08-16","Texas Municipal League is Alliance WC. Please see other payor line for updates. Jen Videan"]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-16",""]
["Taylor Brown",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45117,"","","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",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Payor Follow Up","","","","2023-08-23","08.23.2023 S/W Win of Aetna @ 800-3531232, provider is out of network. No pending application. To be credentialed and participating, visit portal Aetna @ www.aetna.com for online application and select join our network/request participation form and fill out/submit to get the request id#. TAT 90-120 buss days. Call ref# 6160341590. -Mark Morado."]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - 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",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","In Process","Payor Follow Up","","","","2023-09-19","Payor has confirmed the application is complete and has been forwarded to credentialing for review. Reference number 13387740  MS"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-06-28","6/28/2023- per notification form, provider will maintain own CAQH - kavello"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Superior enrollment.  Delegated roster submitted.  DCannon"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Multiplan enrollment.  Delegated roster submitted.  DCannon"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","In Process","Application Submitted","","","","2023-08-23","Provider was not Tricare certified, so I have submitted all enrollment documents via fax in order to have her certified. Once she is certified, we can then submit the request to link her to each location. MS"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Esther Ebele Ihediwa",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Madhusmita Panda, MD",1134756364,"","TX","PE - Premier Family Care, Inc","Wellcare","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Superior enrollment.  Delegated roster submitted.  DCannon"]
["Madhusmita Panda, MD",1134756364,"","TX","PE - Premier Family Care, Inc","Superior","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Madhusmita Panda, MD",1134756364,"","TX","PE - Premier Family Care, Inc","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Madhusmita Panda, MD",1134756364,"","TX","PE - Premier Family Care, Inc","TriCare Standard","In Process","Confirm Par Status","","","","2023-08-25","Provider is not Tricare Certified. Application is electronic.  MS"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-09-06","Pending Medicare approval. MS"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, 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."]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-09-02","Requested access to this TIN for enrollment. MS"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","In Process","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Superior enrollment. Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","In Process","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Superior enrollment. Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","2Y3057","","2023-08-29","Received completed enrollment. MS"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-09-06","I attempted to enroll with RR MCR, but the information is not yet in their system for me to enroll. I will try back in 30 days. MS"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-08-23","Application to link provider to the Briarwood location has been submitted via the Tricare portal. MS"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-08-23","Application to link provider to the Briarwood location has been submitted via the Tricare portal. MS"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-08-23","Tricare is unable to validate the Andrews Hwy location at this time. MS"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-08-23","Tricare is unable to validate Eastridge location at this time. MS"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2023-08-23","Application to link provider to the Briarwood location has been submitted via the Tricare portal. MS"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-12","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-08-18","Provider Information Roster emailed to Karina Garcia at Corvel. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-08","TSCA and required documents emailed to spneast@sedgwickcms.com. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-08-15","See status updates under Alliance WC payor line. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-08-15","See status updates under Alliance WC payor line. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","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",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Tiffany Nicol Bynum",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Superior enrollment.  Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending UHC enrollment.  Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2023-09-15","9/15/2023 Pending Multiplan enrollment.  Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2023-08-18","Enrollment stopped for this location as it has been termed in the Corvel system by Midland 6/9/2023. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-12","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","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",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","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",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-11",""]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-11",""]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","","","","2023-09-08","Entered valid CAQH login info and reattested.      Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Payor Follow Up","","","","2023-09-19","Per michelle.killough@pswca.org, provider has been approved to join the network. Submit Provider Data Form and required documents. \n\nEmailed Provider Data Form and required documents to michelle.killough@pswca.org. Jen Videan"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Receipt Validated","","","","2023-08-24","Received confirmation email from Cigna. The application is being reviewed. Reference # 13425141 MS"]
["Tiffany Nicol Bynum",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Payor Receipt Validated","","","","2023-08-24","Received confirmation email from Cigna. The application is being reviewed. Reference # 13425141 MS"]
["Rony Ninan, MD",1750526182,"","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-08-31",""]
["Rony Ninan, MD",1750526182,"","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","In Process","Add Info Submitted","","","","2023-09-12","9/12/2023 Emailed requested additional information - Scott & White Provider Data form, hospital privilege form and W-9.   DCannon"]
["Rony Ninan, MD",1750526182,"","TX","PE - Premier Family Care, Inc","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder email for provider to sign. MS"]
["Rony Ninan, MD",1750526182,"","TX","PE - Premier Family Care, Inc","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-08-31","8/31/2023 Pending UHC enrollment.  DCannon"]
["Amanda Dee Flores",1083394977,"","TX","PE - West Texas Allergy, PA","Medicaid","Pending Other Enrollment","Pending Medicare","","","","2023-09-06",""]
["Amanda Dee Flores",1083394977,"","TX","PE - West Texas Allergy, PA","Galaxy Health","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Amanda Dee Flores",1083394977,"","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Amanda Dee Flores",1083394977,"","TX","PE - West Texas Allergy, PA","Medicare","In Process","Sent to Provider For Signature","","","","2023-09-19","Sent to client for signatures. MS"]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Aetna","In Process","Pending PSV","","","","2023-09-19",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","United Health Care","Provider Load","Pending PSV","","","","2023-09-19",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","TriCare Standard","Provider Load","Provider Load","","","","2023-09-18",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Omni PPO","In Process","Pending PSV","","","","2023-09-19",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Humana","In Process","Pending PSV","","","","2023-09-19",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Cigna","Provider Load","Provider Load","","","","2023-09-18",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Tricare Prime","Provider Load","Provider Load","","","","2023-09-18",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Superior","In Process","Pending PSV","","","","2023-09-19",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-09-19","9/19/2023 Pending UHC enrollment.  DCannon"]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Multiplan","In Process","Pending PSV","","","","2023-09-19",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Multiplan","In Process","Pending PSV","","","","2023-09-19",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","In Process","Pending PSV","","","","2023-09-19",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Amerigroup","In Process","Pending PSV","","","","2023-09-19",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","Amerigroup","In Process","Pending PSV","","","","2023-09-19",""]
["Briana Janene Smith",1215488754,"","TX","PE - Midland Community Healthcare Services","IMS","In Process","Pending PSV","","","","2023-09-19",""]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Sedgwick","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with WIN network in which this payor is included (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","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"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Omni PPO","Participating","Enrollment Complete","2010-12-29","1356484497","","2020-06-29","06/29/2020 - confirmed that IMS is effective, therefore this enrollment is also effective - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete",40391,"1356484497","","2020-08-26","08/26/2020 - Moved to completed status after reviewing Follow UP Complete note - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2015-03-24","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 3/24/2015.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2015-03-24","1356484497","","2020-02-12","02/12/2020 - Rec'd confirmation through payer portal: Provider: James Barnett \nNetwork: MPI\nNetwork Participation effective:3/24/2015\nContract Source Group contract through: DELEGATED PARTY: West Texas Physicians Alliance - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology 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.\""]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Aetna","Participating","Enrollment Complete","2020-08-01","1356484497","","2020-09-22","09/22/2020 - Rec'd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location - Stacey Hudak"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1124009766","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","USA PPO","Participating","Enrollment Complete","2002-11-15","1124009766","752784378","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Cigna","Participating","Enrollment Complete","2012-01-24","1124009766","","2020-04-22","04/22/2020--SW Sharon of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 1/24/2012. Location is on file. Call ref# Sharon4202020.\ncopied note from spreadsheet-tisha rader"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Rail Road Medicare","Participating","Enrollment Complete","1997-10-01","110177800","Individual","2020-08-13","8/13/2020 - confirmed this provider is already enrolled through payer site - Stacey Hudak"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-12-06","10122396","","2022-02-26","2/26/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2021-11-17","","","2022-06-21","6/21/2022 Per Tricare portal, provider is certified and linked to location eff 11/17/2021. DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2021-11-17","","","2022-06-21","6/21/2022 Per Tricare portal, provider is certified and linked to location eff 11/17/2021. DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2021-11-15","4361906","","2021-12-29","12/29/2021 Per F/U Notes - S/W Christine of Aetna @ 8003531232, NPI# for the provider is on file, shows linked and PAR under the group and TIN# ( Individual contract ) effective 11/15/2021, the physical location is on file, The provider ID is 4361906.   DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete",44713,"","","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","","Scott&White (First Care)","Participating","Enrollment Complete","2021-11-05","","","2022-01-11","1/11/2022 Rcvd approval letter from Scott and White.  Provider is PAR and linked to group/TIN effective 11/05/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","IMS","Participating","Enrollment Complete",44536,"","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","IMS","Participating","Enrollment Complete",44536,"","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2021-12-15","","","2022-02-08","2/8/2022 Rcvd Multiplan approval letter, provider is PAR and linked to group/location effective 12/15/2022.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2021-12-06","","","2022-03-11","03/11/2022  Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2021-12-01","1225170103","","2022-08-04","8/4/2022 Per TMHP web portal provider is PAR and linked to group effective 12/1/2021.  PID# 1225170103.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-01-22","8020391","","2021-11-25","11/25/21 received letter from pdmcogz@cigna.com, enrollment complete. PID 8020391 eff 1/22/2022"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1091200","","2020-03-24","3/24/2020-received email with roster stating provider PAR 9/1/2008 PID # 1091200\ntisha rader"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Boon Chapman","Participating","Enrollment Complete","2015-06-09","","","2020-10-05","Enrolled thru Multiplan"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Aetna","Participating","Enrollment Complete","2014-09-29","1659366433","","2020-03-25","3/25/2020--S/W Mary of Aetna @ 8003531232,  provider NPI# is on file for the provider and is participating effective 09/29/2014 under the group and TIN#. Physical location is on file. DIRECT CONTRACT --Call ref#: 5194781237. \nTISHA RADER"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","IMS","Participating","Enrollment Complete","1999-04-01","1659366433","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","United Health Care","Participating","Enrollment Complete",44256,"","","2021-08-24","8/24/2021 Received an email from united_healthcare_provider_operations@uhc.com with confirmation provider has been loaded under group Tax ID and location with effective date requested 3/1/2021. KFrazier"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Amerigroup","Participating","Enrollment Complete","2021-08-01","12731150","","2022-05-19","5/19/2022 Per roster received from Amerigroup provider is PAR and linked to group TIN effective 8/1/2021.  PID #  12731150.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-09-06",""]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Submitted roster to Karina Garcia at Corvel to add provider under TIN and add locations. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Medicaid","Participating","Payor Follow Up","2023-04-20","","","2023-08-23","8/23/2023 Called TMHP 800-925-9126 spoke w/ Priscilla.  Per Priscilla the effective date of 4/20/2023 given is correct because no PTAN was listed on the application to back date the enrollment.  **You cannot link Dr. Wilson to the COM Medicare group because is a mass immunization biller.  An escalation has been submitted and advised to check back in 30 days.  Ticket # 46945819000.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-08-01","1103233","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/1/2021.  PID #1103233  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Coventry panel closed at this time."]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2021-07-26","","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2021-07-26","9800227","","2021-08-31","8/31/2021 Received an email from pdmcogz@cigna.com with confirmation provider has been loaded under group Tax ID and all practice locations effective 7/26/2021 and assigned provider ID 9800227. KFrazier"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Coventry Workers Comp","Participating","Enrollment Complete","2021-08-01","","","2021-10-08","10/8/21 Recevied email from CoventryProvider@cvty.us.com, provider effective 8/1/2021. Cbankston"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2022-08-01","","","2022-08-04","8/4/2022 Received approval letter for TX Mutual/Workwell.  Provider is PAR effective 8/1/2022.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",44403,"","",44533,"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 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-12","Submitted application via pswca.org. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Roster submitted.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Coventry panel closed at this time.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-07-26","","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from August has been completed and provider is PAR effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Coventry Panel closed at this time.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-12-01","1L5835","00008AH","2021-01-29","1/29/2021 Received Medicare approval notice for provider's reassignment to group effective 12/1/2020 and assigned PTAN 1L5835. KFrazier"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2021-11-12","","","2022-02-24","2/24/2022 Per Humana Tricare portal provider is PAR and linked to group TIN/location effective 11/12/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2021-08-01","","","2021-10-08","10/8/21 Recevied email from CoventryProvider@cvty.us.com, provider effective 8/1/2021. Cbankston"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2021-11-16","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/16/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-09-06",""]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",45047,"","","2023-09-02",""]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 9800227 DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-01-07","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Pending Info/Document","","","","2023-09-14","Emailed Sedgwick forms to Priscilla and Neeraja for Dr. Wilson to complete and sign. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Pending Info/Document","","","","2023-09-14","Emailed Sedgwick forms to Priscilla and Neeraja for Dr. Wilson to complete and sign. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-14","Emailed TSCA to Texas Mutual requesting to add additional location to Dr. Wilson's profile. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2022-04-05","4/5/2022 Rcvd email from Joe Rodriguez at Amerigroup confirming provider is PAR and linked to group TIN/location effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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.\""]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Coventry panel is closed at this time.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-14","Added practice locations, COI and re-attested. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-09-14","Added practice locations, COI and re-attested. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-01-07","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 01/07/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2021-07-26","Q00177598","DX4335","2021-12-08","12/8/2021 Rcvd RR Medicare PTAN Approval letter instantly.  RR Medicare PTAN#  Q00177598 - effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-08-15","8/15/2023 Pending UHC enrollment.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-01-07","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-01-07","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-05","","","2021-03-24","3/24/2021 Rcvd confirmation email from hpcredentialinggroup@BSWHealth.org that provider is participating with TIN and location effective 3/5/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2021-07-26","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-05","See status updates under Alliance WC payor line. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2021-11-16","2438204","","2021-11-12","11/12/2021 Received roster from payor confirming provider is participating under group Tax ID and location effective 11/16/2021 with assigned ID 2438204. KFrazier"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","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,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Cigna","Participating","Enrollment Complete","2012-07-01","9750907","","2020-06-25","6-25-2020 - Moved to completed status based on info rec'd during follow up complete call - Stacey Hudak"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","United Health Care","Participating","Enrollment Complete","2016-06-04","1629074984","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up note - Stacey Hudak"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Medicaid","Participating","Enrollment Complete","","132863503","212775501","2020-09-25","09/25/2020 - Rec'd email from the clinic with TPI (provider and group only) typed in. No actual letter from the payer naming the group - Stacey Hudak"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","10120298","","2020-07-21","07/21/2020 - Rec'd email from the payer indicating this provider/service location/TIN are affiliated under PRIMED delegation - Stacey Hudak"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1094380","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 9/1/2008  PID # 1094380\ntisha rader"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2013-11-01","1942216122","460950925","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2012-10-01","1942216122","","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"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2016-11-01","1942216122","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - 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","PE - Permian Gastroenterology PA","Boon Chapman","Participating","Enrollment Complete","1996-10-01","","","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 10/1/1996.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",45017,"","","2023-08-22","Received confirmation. MS"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2023-07-01","","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","Cigna","In Process","Payor Follow Up","","","","2023-09-15","Payer confirmed the application is complete and has been sent to credentialing for review. Reference number 13389129  MS"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2023-05-25","","","2023-08-23","Confirmed provider is active and linked to location. MS"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2023-08-25","Application submitted via online portal. MS"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-18",""]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","Humana","In Process","Payor Follow Up","","","","2023-09-01","9/1/2023 Sent follow-up email to Marcus Wester at Humana to check status of June monthly delegated roster submission.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2014-01-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 1/1/2014. KFrazier"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2014-01-01","2019864","2559513","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 1/1/2014. KFrazier"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Enrollment Complete","2013-08-01","1013923291","West Texas Physician Alliance","2020-09-28","09/28/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - 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"]
["Sari A Nabulsi, MD",1740289297,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1092122","","2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 9/1/2008 PID # 1092122\ntisha rader"]
["Sari A Nabulsi, MD",1740289297,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","Omni PPO","Participating","Enrollment Complete","2019-09-01","1740289297","","2020-07-27","IMS complete"]
["Sari A Nabulsi, MD",1740289297,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","Cigna","Participating","Enrollment Complete","2010-09-23","1740289297","","2020-04-22","04/22/2020--S/W Anna of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 09/23/2010 under the group and TIN#. Physical location is on file. Call ref# Anna04202020.\ncopied note from spreadsheet-tisha rader"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-04-01","1679568380","","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"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1679568380","","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 W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1900818","","2020-12-17","12/17/2020 - Rcvd confirmation email from payor that credentialing has been completed.  CPID 1900818 effective 9/1/2020.  DCannon"]
["John W Foster, Jr, MD",1679568380,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-08-16","1208794","","2021-08-17","8/17/2021 Received an email from discovercigna@information.cigna.com confirming provider is participating under group Tax ID effective 8/16/2021 with assigned provider identification number 1208794. KFrazier"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Omni PPO","Participating","Enrollment Complete","2007-11-07","1811900657","","2020-06-25",""]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","TriCare Standard","Participating","Enrollment Complete","2007-02-23","1811900657","","2020-05-01","05/01/2020 - Rec'd access to the TIN through the payer portal. The provider IS PAR with this payer/service location - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","United Health Care","Participating","Enrollment Complete","2020-01-01","1811900657","","2020-08-03","8/3/2020 - Emailed Tracy Diapolo and confirmed this provider is NOT with PriMed. That agreement has dissoled with UHC and the phone rep was incorrect in sharing this information. However, she confirmed the provider has been credentialed directly with UHC and all else is well. - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Boon Chapman","Participating","Enrollment Complete","2007-06-01","1811900657","","2020-10-05","Enrolled thru PHCS"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Caprock (CapStar)","Participating","Enrollment Complete","2013-01-24","1770564080","","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"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Rail Road Medicare","Participating","Enrollment Complete","2013-04-01"," P01188488"," DT8096","2020-04-22","04/22/2020 - Verified proivder is EFF thorugh payer payer site - Stacey Hudak"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","United Health Care","Participating","Enrollment Complete",43831,"1760485502","",44074,"08/31/2020 - Moved to completed status after reviewing Follow Up Completed note - Stacey Hudak"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","Medicaid","Participating","Enrollment Complete","","144105701","","2020-08-26","8/26/2020 - the clinic only provider an TPI number. I was not given an effective date. - Stacey Hudak"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","First Health Coventry","Participating","Enrollment Complete",39692,"1760485502","",44022,"07/10/2020 - moved to completed status per notes in Follow Up Complete  - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",42736,"1295724698","",44026,"07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","PE - 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: P","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-08-03","2026473","","2021-08-05","8/4/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 8/3/2021 with assigned provider number 2026473. KFrazier"]
["Kirit N Patel, MD",1295724698,"75-2656723: P","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2011-09-01","1295724698","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 09/01/2011. – Archie Candiasan"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",43326,"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: P","TX","PE - Premier Family Care, Inc","Liberty Mutual","Participating","Enrollment Complete","2011-09-01","1295724698","752656723","2020-08-19","Confirmed provider is participating with WIN network which includes this payor (list of networks attached). Kimberly Frazier"]
["Kirit N Patel, MD",1295724698,"75-2656723: S","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","046690605","","2020-01-29","01/29/2020 - Found provider PAR through payer portal and linked to correct service location. Proivder PAR with the following plans: SUPERIOR - FOSTER CARE, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Superior Health Plan - Lubbock, Superior Health Plan - MRSA West, Amerigroup - MRSA West, Superior HealthPlan - MRSA West, Amerigroup Texas, Inc. - MRSA West, Superior Health Plan - MRSA West - Stacey Hudak"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-10-29","1912100850","","2023-07-11","Received confirmation from Client. MS"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2012-03-01","01448905","","2021-11-15","11/15/2021 Per Amerigroup roster provider is PAR and linked to group TIN/location effective 3/1/2012.  DCannon"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2021-12-01","1912100850","","2021-12-07","12/7/2021 Rcvd email from SuperiorDelegation that November delegation roster has been completed and providers are loaded under appropriate group TIN/locations effective 12/1/2021.  DCannon"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","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"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","United Health Care","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","PE - P. Douglas Cochran, MD PA","Aetna","Participating","Enrollment Complete",41408,"1316026396","","2020-04-23","04/23/2020--S/W EL of Aetna @ 18003531232, provider NPI# is on file for the provider and is participating effective 05/14/2013 under the group and TIN#. Physical location is on file. Call ref# 5235916733. \ncopied note from spreadsheet-tisha rader"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2015-08-28","03421119","","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 8/28/2015;  PLUS - eff 8/28/2015, Star_Kids - eff 11/1/2016.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-10","Per Liberty Mutual any updates to the provider record would need to be processed through Coventry and Coventry panel is closed. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2015-05-09","318466ZP5M","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/9/2015.  PID # 318466ZP5M.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",45047,"","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  PID # 2230880.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-05-15","5/15/2023 Pending UHC enrollment.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1912991084","","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"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2017-09-21","1912991084","","2020-06-09","06/09/2020 - S/W Nina of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 09/21/17 under the group and TIN with delegated agreement with Primed Health Network. Physical location is on file. Provider ID# 4417046. Call ref# 5309938401 - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-08-16","8/16/2023 Roster submitted to Aetna to add provider to new locations.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-25","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","2013-04-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 4/1/2013. KFrazier"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House 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","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2015-06-01","1912991084","","2020-04-22","04/22/2020--S/W Rica of Cigna @ 18008824462.  Per rep the Provider is on file, linked & participating under the GRP & TIN effective 6/1/15. Physical Location is on file. Provider ID #4160673. Call ref # Rica04172020.\ncopied note from spreadsheet-tisha rader"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","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"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","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"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 4160673 DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-08-23","08.23.2023: Called Sedgwick (Through USA MCO) @ 1-800-625-6588. Waited on line for 44 minutes but still no rep available. Verification request has been emailed  to sedgwick@sedgwick.com to verify provider credentialing status.-Danico Gabriel Melendres"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-08-23","08.23.2023: Called Sedgwick (Through USA MCO) @ 1-800-625-6588. Waited on line for 44 minutes but still no rep available. Verification request has been emailed  to sedgwick@sedgwick.com to verify provider credentialing status.-Danico Gabriel Melendres"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2013-04-01","1912991084","","2020-10-08","10/8/2020 - moved to completed status - but this provider is through a delegated payer - Prime Health Network - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-07-24","7/24/2023 Pending UHC enrollment.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-28","Tricare does not find the Eastridge address as a valid address, therefore I am unable to add this location to the group. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document",45135,"","","2023-07-28","Tricare does not find the Andrews Hwy address as a valid address, therefore I am unable to add this location to the group. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","2023-07-28","","","2023-07-28","Tricare does not find the Eastridge address as a valid address, therefore I am unable to add this location to the group. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2015-09-01","","","2023-08-18","8/18/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 9/1/2015.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Participating","Enrollment Complete","2016-01-14","1912991084","","2020-07-06","07/06/2020 - Rec'd email from the payer stating \" Here is the following information we have on file for Beck, Terry:\n\nNetwork:  MPI\nTIN: 47-3465832\nNetwork Participation effective: 1/14/16 Contract Source Group contract through: Individual Contract\" - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1912991084","","2020-08-24",""]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - 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","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-09-12","Q00346339","CE1588","2022-10-15","10/15/2022 Rcvd RR Medicare approval letter.  PTAN # Q00346339 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-09-12","Q00346339","CE1588","2022-10-15","10/15/2022 Rcvd RR Medicare approval letter.  PTAN # Q00346339 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-11-28","11/28/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-11-28","11/28/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44816,"3714369","","2022-11-08","11/8/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 9/12/2022.  PID # 3714369.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-09-12","","","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"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-09-13","","","2023-05-24","Confirmed via HM portal. MS"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-09-13","","","2023-05-24","Confirmed via HM portal. MS"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-10-10","","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 10/10/2022.  PID# 14614726.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44841,"","","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","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","","",45082,"6/5/2023- CAQH Reattested by Data Services - kavello"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-09-12","2I8228","0008AH","2022-09-21","9/21/2022 Rcvd Medicare approval letter from Candace Wynne.  PTAN # 2I8228 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-09-12","2I8228","0008AH","2022-09-21","9/21/2022 Rcvd Medicare approval letter from Candace Wynne.  PTAN # 2I8228 - effective 9/12/2022.  DCannon"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","IMS","Participating","Enrollment Complete","2012-01-01","","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Rail Road Medicare","Participating","Enrollment Complete",35704,"480027409","N/A - no group link/PTAN","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","Amerigroup","Participating","Enrollment Complete","2015-12-09","1346236924","","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"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Caprock (CapStar)","Participating","Enrollment Complete","2012-01-01","1346236924","","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"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","PE - Vincent P. Rascon","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1346236924","","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"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: P","TX","","Triwest VA","Participating","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Vincent P Rascon, DPM",1346236924,"91-1559006: S","TX","PE - Vincent P. Rascon","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1346236924","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2020-10-01","1730181389","","2020-10-02","10/02/2020 - rec'd email from the payer confirming this provider has been added to the primed delegation - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1730181389","","2020-07-01","07/01/2020 - rec'd email confirmation from the payer that this provider is EFF - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2002-04-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 4/1/2002.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1730181389","","2020-08-21",""]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Hartford","Panel Closed","Panel Closed","","","","2023-07-25","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"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Hartford","Panel Closed","Panel Closed","","","","2023-07-25","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"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","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"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","USA PPO","Participating","Enrollment Complete","2003-02-11","1730181389","751997880","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Texas Mutual","In Process","Pending Info/Document","","","","2023-09-11","Emailed Texas Mutual application and questionnaire to Priscilla and Neeraja for Dr. Waddington to complete and return with current driver's license, photo and CV. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-06-05","6/5/2023 - CAQH Reattested by Data Services - kavello"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","CAQH","Participating","CAQH Reattested","2023-06-05","10778944","","2023-06-05","6/5/2023 - CAQH Reattested by Data Services - kavello"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician 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."]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Wellcare","Participating","Enrollment Complete",44501,"","","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","","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,"26-3789190","TX","","Amerigroup","Participating","Enrollment Complete","2012-03-01","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 3/1/2012, MEDICARE - eff 8/1/2012, C-SNP - eff 1/1/2017, OTHER - eff 1/1/2021, OTHER - eff 1/1/2020,  PLUS - eff 3/1/2012, Star_Kids - eff 11/1/2016.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Zurich","Panel Closed","Panel Closed","","","","2023-07-25","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"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","IMS","Participating","Enrollment Complete","2001-01-15","1316965403","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1122340","","2020-03-24","3/24/2020-received email with roster stating provider PAR 9/1/2008 PID # 1122340\ntisha rader"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Aetna","Participating","Enrollment Complete","2020-03-15","1316965403","","2020-03-24","3/24/2020--S/W Erickof Aetna @ 18003531232, provider NPI# is on file for the provider and is participating effective 03/15/2020 under the group and TIN#. Physical location is on file. DIRECT CONTRACT--Call ref# 5192739438.\ntisha rader"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Omni PPO","Participating","Enrollment Complete","2001-01-15","1316965403","","2020-06-25",""]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Tricare Prime","Panel Closed","Panel Closed","","","","2021-07-09","7/9/2021 The payor is no longer extending contracts to new groups at this time; however, required to check on-line for future openings of the panel. KFrazier"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","USA PPO","Participating","Enrollment Complete",44235,"","","2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 2/8/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","United Health Care","Participating","Enrollment Complete","2009-10-01","MPIN 2403042","204063608","2020-12-28","12/28/2020 Received email confirmation and report of provider's participation under group with initial effective date of 10/1/2009; however, they are non-par with all Medicare networks (i.e. AARP, Medicare advantage, etc.). KFrazier"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","IMS","Participating","Enrollment Complete","2014-10-31","1093821274","","2020-07-01","07/01/2020 - Rec'd confirmation email from the payer stating this provider is EFF - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","United Health Care","Participating","Enrollment Complete","2015-09-01","1093821274","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Aetna","Participating","Enrollment Complete","2014-11-15","1093821274","","2020-09-22","09/22/2020 - Rec'd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","","Boon Chapman","Participating","Enrollment Complete","2020-04-01","1780892760","","2020-10-05","Enrollment through PHCS"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","PE - Permian Basin Kidney Center Inc","First Health Coventry","Terminated","Enrollment Stopped","","","","2022-06-19","6/19/2022 Per email received from Priscilla Albertine at MQA from a follow-up email she received from First Health provider was termed from health plan 6/30/2019.  DCannon"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","","USA PPO","Participating","Enrollment Complete","2021-01-26","1160322","","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"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","","IMS","Participating","Enrollment Complete","2019-05-01","1780892760","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","","Amerigroup","Participating","Enrollment Complete","2020-04-15","07110928","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","","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","PE - Permian Basin Kidney Center Inc","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","TX","PE - Permian Basin Kidney Center 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"]
["Anand C Reddy, MD",1780892760,"81-3411343: P","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"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-02-12","","","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 2/12/2020.   DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-11-29","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","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","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete",44562,"","","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","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04","8/3/2021 Medicaid enrollment is done in-house by MCHS.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-07-29","1093928913","","2020-08-06","8/6/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Jul 29, 2020 9:56:56 AM. Your request was assigned reference number PR-5410028 .\" - Stacey Hudak"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-02-12","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 2/12/2020.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1093928913","","2020-10-08","10/8/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","9672268","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 9672268  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","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, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","In Process","Payor Follow Up","","","",45184,"9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-05-10",""]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2023-05-15","","","2023-05-24","Confirmed via HM portal. MS"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2020-09-17","","","2022-04-13","4/13/2022 Per roster from IMS/Omni provider is PAR and linked to group TIN/location effective 9/17/2020.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","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","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete",44348,"","","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 # 9132703  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","293166YM2M","00304W","2020-09-22","9/22/2020 - created this payer line to house effective information - this is not maintained by Symplr. This is maintained by IN HOUSE by the clinic\n\nRec'd confirmation from the clinic that this service location has been approved under the group enrollment - Stacey Hudak"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","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","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2020-09-17","","","2022-04-13","4/13/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 9/17/2020.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete",44501,"","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete",44501,"","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2013-08-29","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 8/29/2013.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete",44531,"","","2021-12-08","12/8/21 Per provider portal, provider is linked to this location. Cbankston"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete",42605,"1306167309","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 8-26-2016 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1306167309","","",""]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-06-22","355008ZV0W","519061","2020-04-20","04/20/2020 - found EFF info through group PECOS to update payer lines - Stacey Hudak"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","","Triwest VA","Enrollment Stopped","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","CAQH","Participating","CAQH Reattested","2023-06-05","","","2023-06-05","6/5/2023 - CAQH Reattested by Data Services Team - kavello"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Cigna","In Process","Application/Contract Requested","","","","2023-09-14","Received contract from Cigna. I've forwarded this over to the client to complete. MS"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - 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"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology 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.\""]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete",43619,"1306162557","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete notes - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete","2018-06-19","1306162557","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-29","1306162557","","2020-08-19","8/19/2020 - Rec'd spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - 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,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Ambetter","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","tx","PE - 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,"81-3411343","TX","","Triwest VA","Participating","Enrollment Complete","2021-05-15","","","2021-05-31","5/31/2021 Received forwarded email from Rebecca Pontaski with confirmation provider is participating with VACCN (TriWest) effective 5/15/2021. KFrazier"]
["Asif AK Ansari, MD",1528299872,"81-3411343","tx","PE - Permian Basin Kidney Center Inc","Amerigroup","Participating","Enrollment Complete",43908,"","","2023-08-31","8/31/2023 Per Amerigroup portal provider has been added to new location.  Provider effective date 3/18/2020.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","Humana","Participating","Enrollment Complete","2019-06-04","1528299872","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Galaxy Health","Participating","Enrollment Complete",43709,"1528299872","","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"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Humana","Participating","Enrollment Complete","2019-06-04","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 6/4/2019.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Wellmed","Participating","Enrollment Complete","2023-03-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/24/2023.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","tx","","Ambetter","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","Medicare","Participating","Enrollment Complete","2019-05-01","792562","791814","2020-04-29","04/29/2020 - Was able to confirm the providers enrollment through PECOS login - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Rail Road Medicare","Participating","Enrollment Complete",43586,"P02323200","DZ2789","2020-05-04","05/04/2020 - verified through portal and moved to completed status - Stacey Hudak"]
["Venus M Skeen, DNP",1104229293,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1104229293","","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"]
["Venus M Skeen, DNP",1104229293,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1104229293","","2020-08-13","IMS is complete"]
["Venus M Skeen, DNP",1104229293,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Venus M Skeen, DNP",1104229293,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Venus M Skeen, DNP",1104229293,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1104229293","","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"]
["Venus M Skeen, DNP",1104229293,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1104229293","","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"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Facility Enrollment","Facility Enrollment","","","","2020-10-09","10/9/2020 - Rec'd email from the clinic contact (Regina Stieger) stating that this payer is contracted through a facility enrollment - Stacey Hudak"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-12-01","","","2023-08-23","08.23.2023 S/W Trina of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 12/01/2018. Provider ID 2672850. Physical location is on file. Call ref#:725002. - Danico Gabriel Melendres"]
["Jason P. Cooper, PA",1063591493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-08","08/08/2023. 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"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","2015-09-01","","","2020-08-28","08/28/2020 - S/W Kim of Gallagher @ 800-243-2336, provider NPI is on file and participating effective 09/01/15 as PA and 01/01/15 as Internal Medicine under the group and TIN. Physical location is on file. Call ref#  181602659 - Moises Cipriano"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2019-07-01","","","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 7/1/2019.  DCannon"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-08","Per Dee Dee Johnson at Texas Mutual email TSCA and they will get locations added to provider's profile. Added locations to CAQH, downloaded new TSCA and emailed to wwtxcontracts@texasmutual.com. Jen Videan"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-14","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Jason P. Cooper, PA",1063591493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-22","08/22/2023  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"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2023-08-23","08.23.2023: Called Sedgwick (Through USA MCO) @ 1-800-625-6588. Waited on line for 44 minutes but still no rep available. Verification request has been emailed  to sedgwick@sedgwick.com to verify provider credentialing status.-Danico Gabriel Melendres"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2018-12-31","1212945","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/31/2018.  DCannon"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1063591493","","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"]
["Jason P. Cooper, PA",1063591493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-08","08/08/2023. 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"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2023-08-22","8/22/2023 Sent follow-up email to Marcus Wester at Humana to check status of May monthly delegated roster submission.  DCannon"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-06-02","005249268","","2023-09-05","9/5/2023 Per email from UHC - May monthly delegated roster has been completed.   Provider is PAR and linked to group TIN/location effective 6/2/2020.  DCannon"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",43349,"708658","","2020-06-15","06/15/2020 - rec'd email from the clnic stating this provider is EFF - Stacey Hudak"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Jason P. Cooper, PA",1063591493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to Multiplan to check status of August delegated roster provider loads.  DCannon"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2019-01-15","1063591493","","2020-06-09","06/09/2020 - S/W Nina of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 01/15/19 under the group and TIN with delegated agreement with Primed Health Network. Physical location is on file. Provider ID# 4777884. Call ref# 5309938401 - Stacey Hudak"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-07-27","Tricare isn't allowing me to submit the application for Eastridge as this is not a valid address to enroll. MS"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","","","","2023-09-06","Provider has been added to the Briarwood location effective 7/28/23. MS"]
["Jason P. Cooper, PA",1063591493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Pending Info/Document","","","","2023-07-27","Tricare isn't allowing me to submit the application for Andrews Hwy. as this is not a valid address to enroll. MS"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2018-12-01","1700","","2021-11-23","11/23/21 Received email from wwtxcontracts@texasmutual.com, recredentialing is complete. Cbankston"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2019-08-17","1063591493","","2020-06-25","06/25/2020 - Verified this provider is participating with this group through payer portal. This group is NON NETWORKED, but this provider is certified - Stacey Hudak"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-27","7/27/2023 Rcvd email confirmation from Cigna that this group and Tax ID 47-3465832 are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the providers do not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary.  DCannon"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2018-09-06","P02104426","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Jason P. Cooper, PA",1063591493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-06-05","14328647","","2023-09-08","Added practice locations and re-attested. Jen Videan"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-24","","","2021-02-11","2/11/2021 Received email of provider approval from BSWHPEXPEDITES@BSWHealth.org with an effective date of 2/24/2021 and asks to allow 3-4 weeks before submitting claims so they may complete the configuration of provider load in their system. KFrazier"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested",45134,"","","2023-07-27","7/27/2023 CAQH reviewed and re-attested.  Uploaded current COI to CAQH portal.  DCannon"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-01-07","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 01/07/2021.  DCannon"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-04-09","4/9/2021 Provider is listed on the HealthSmart website provider directory as participating at location.  I have requested an updated delegated roster from cgc.data@healthsmart.com.  DCannon"]
["Nancy Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Nancy Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Nancy Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2020-12-01","8849849","","2021-03-15","3/15/21 Received an email from PDMCOGZ@cigna.com confirming provider has been loaded under the group Tax ID and location effective 12/1/2020, under internal reference number W202102161535108, and assigned PID 8849849. KFrazier"]
["Nancy Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Texas Mutual","Enrollment Stopped","Enrollment Stopped","","","","2022-03-25","3/25/2022 Per email from Candace, Dr. Asamoa is a hospitalist and does not see work comp patients.  Cbankston"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - 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"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2016-02-15","P01777833","CE1588","2020-04-29","Per web portal, provider is now PAR with effective date 02/15/2016 and individual PTAN of  P01777833."]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-03-13","13683951","","2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2019-09-01","2383552","","2021-05-26","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"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-05-26","2383552","","2021-07-22","7/22/2021 Received an email from PDMCOGZ@cigna.com confirming provider is now participating under group Tax ID effective 5/26/2021 with assigned provider ID 2383552. KFrazier"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723: S","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",42977,"1295109510","","2020-06-05","06/05/2020 - Rec'd email stating this provider is EFF - Stacey Hudak"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2018-01-11","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2016-08-15","536764YV2D"," 320497","2020-01-30","01/30/2020 - Found provider is PAR with Medicare through group enrollment in PECOS - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2016-06-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 6/1/2016. KFrazier"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete","2016-07-28","1215254156","","2020-06-25",""]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete",42597,"P02008203","DU5783","2020-03-10","03/10/2020 - Found EFF information through payer site - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Travelers WC","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","Per request from MQA remove all workers comp payors for this provider. Jen Videan"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Active","CAQH Reattested","2023-06-07","14041680","","2023-06-07","6/7/2023- Updated and Uploaded all provider information in CAQH and reattested - kavello"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Coventry Workers Comp","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","Per request from MQA remove all workers comp payors for this provider. Jen Videan"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Superior","Participating","Enrollment Complete","2023-07-01","1063962355","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Aetna","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received confirmation that provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2023-09-06","Still Pending Medicare. MS"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Pending Other Enrollment","Pending Medicare","","","","2023-06-21",""]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Panel Closed","Panel Closed","","","","2023-06-07",""]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","In Process","Payor Receipt Validated","","","","2023-09-12","Received email from Cigna rep stating that they have received the request to participate and have forwarded the request to Cigna Texas Network Management for processing. BID 13388002 MS"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2023-06-01","1063962355","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Zurich","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","Per request from MQA remove all workers comp payors for this provider. Jen Videan"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","USA PPO","Participating","Enrollment Complete","2023-06-01","1063962355","","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 6/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","7/19/2023 Per request from MQA remove all workers comp payors for this provider.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","7/19/2023 Per request from MQA remove all workers comp payors for this provider.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2023-07-01","1063962355","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2023-07-01","1063962355","","2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Texas Mutual","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","7/19/2023 Per request from MQA remove all workers comp payors for this provider.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Sedgwick","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","7/19/2023 Per request from MQA remove all workers comp payors for this provider.  DCannon"]
["Emily D Satterfield, MSN, FNP-C",1063962355,"75-2781652","TX","PE - West Texas Allergy, PA","Sedgwick","Enrollment Stopped","Enrollment Stopped","","","","2023-07-19","7/19/2023 Per request from MQA remove all workers comp payors for this provider.  DCannon"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01","1467745240","","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"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2019-08-26","1467745240","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2019-08-26","1467745240","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2015-03-28","","","2020-12-24","12/24/2020 Confirmed via Self-Service chat provider is currently certified as non-network provider. KFrazier"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1467745240","","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"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-03","1467745240","","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"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-04-01","","","2021-11-03","11/3/2021 Per follow-up notes.  NPI# for the provider is on file, shows Linked and Certified , In network  under the group and TIN# at this location,  effective 4/1/2021 -  no termination date, Provider ID is 75-2656723-79706-C006.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that February delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 8/1/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2023-07-05","8143656","","2023-06-14","6/14/2023 received confirmation email from Aetna that provider is PAR and linked to group TIN/location effective 7/5/2023.  PID # 8143656.  MS"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",42564,"","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/13/2016.  DCannon"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",42303,"1770883191","752656723",44067,"Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-02-12","1770883191","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 2-12-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete",43322,"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","","Amerigroup","Participating","Enrollment Complete","2015-12-01","1770883191","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Also showing 01/01/2020 and 11/1/16 and 1/1/17 as effective dates.  Tisha Rader"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2015-11-19","1770883191","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2015-10-26","1770883191","","2020-06-25",""]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-07-07","1275044422","52669: West Texas Physicians Alliance Group Cntrct","2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 7/1/2018.  DCannon"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-09-01","1275044422","","2020-09-14","09/14/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Sep 9, 2020 9:21:18 AM. Your request was assigned reference number PR-5483455 .\" - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2018-07-24","1275044422","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 07/24/2018. – Archie Candiasan"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",43874,"1275044422","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - 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: P","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-05-06","","","2022-06-21","6/21/2022  Per Tricare portal, provider has been added to group TIN and location effective 5/6/2022.  DCannon"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723: P","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2018-07-24","1275044422","","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 J Hester, APRN-AGACNP",1275044422,"75-2656723: S","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2018-07-31","1263679","","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"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1013990761","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2011-11-15","1013990761","","2020-06-09","06/09/2020 - Rec'd email from the payer stating this provider is  EFF 11-15-2011 at this service location under  A DELEGATED PRIMED AGREEMENT - stacey hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2017-10-03","12418437","","2022-02-24","2/24/2022 - Per follow-up note from 2/18/2022 -  Provider NPI# is on file for the provider and participating effective 10/03/2017 under the group and TIN#. Provider ID#  12418437. Physical location is on file. Call ref# 7919804 -DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete",44531,"","","2021-12-14","12/14/2021 Provider linked to location per portal as of 12/1/21. Cbankston"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","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","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2018-06-12","1013990761","","2020-08-19","08/19/2020 - Rec'd spreadsheet from the payer confirming this provider is part of the DELEGATED PRIMED AGREEMENT and linked to this TIN/Service Location. This provider is networked with the following: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-10-03","","","2022-02-24","2/24/2022 Per follow-up note on 2/18/2022 - Provider NPI# is on file for the provider and participating effective 10/03/2017 under the group and TIN#. Provider ID#  12418437. Physical location is on file. Call ref# 7919804 -DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete",40787,"1099473","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2011 PID # 1099473\n-tisha rader"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete",43703,"1811086986","",44012,"6/30/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2019-09-01","7615552","","2020-05-14","05/14/2020 - Rec'd email from the payer stating EFF - Stacey Hudak"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2017-07-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 7/3/2017.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete",43678,"1110534","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2019 PID # 1110534\ntisha rader"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2019-08-26","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 8/26/2019.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete",44501,"","","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"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Elisa L Brown, MD",1811086986,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Pending Coventry enrollment.  Coventry panel is closed at this time.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Pending Coventry enrollment.  Coventry panel is closed at this time.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2021-03-24","475554737 79701 A056","","2021-04-02","4/2/2021 Per Humana Millitary portal provider is certified and linked to TIN and location effective 3/24/2021.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-04-13","","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 4/13/2021. DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete",44788,"3560602","","2022-11-30","11/30/2022 Per follow-up note - 11.21.2022 S/W Lance of Coventry Workers Comp @ 800-937-6824. Per rep, provider is showing participating with an Effective date 08/15/2022 and link under the Group and TIN. Provider ID 3560602.   Service location is on file. DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 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"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2022-07-01","","","2022-11-01","11/1/2022 Per email received from Vernita Young July monthly delegated roster is complete and provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 8228233 DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-08-26","","","2022-09-07","Received confirmation email with approval letter (attached). MStone"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-08-26","","","2022-09-07","Received confirmation email with approval letter (attached). MStone"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00306896","DX4335","2022-08-11","8/11/2022 Rcvd RR Medicare approval letter.  PTAN # Q00306896 - effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-01","9/1/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-26","","","2022-11-16","11/16/2022 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 8/29/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2023-09-05","See status updates under Alliance WC payor line.  Jen Videan"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-01","","","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 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-01","","","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 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-08-26","","","2022-09-16","9/16/2022 Enrolled through PSWCA provider is PAR and linked to group TIN/locations effective 8/26/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Pending Coventry enrollment.  Coventry panel is closed at this time."]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-07-01","2703063","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID# 2703063  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-06-13",""]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-01","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/1/2022.   MPIN# 001163117.   DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2022-05-01","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2022-05-01","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for June is complete and provider is loaded effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-07-01","","","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 7/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Sedgwick and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2F3553","423838","2022-08-11","8/11/2022 Per PECOS provider is PAR and linked to group.  PTAN # 2F3553 - effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","2F3553","423838","2022-08-11","8/11/2022 Per PECOS provider is PAR and linked to group.  PTAN # 2F3553 - effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Sedgwick and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2023-09-06","Emailed roster to Karina Garcia at Corvel to add provider to TIN/locations. Jen Videan"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-01",""]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Zurich and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","2022-08-15","","","2022-12-15","12/15/2022 Per Coventry WC website provider is PAR in Travelers WC and linked to TIN/locations effective 8/15/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-14","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/14/2023.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-07-01","","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2022-07-01","","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 7/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-07-01","2703063","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID #2703063  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","5951375","","2022-07-28","7/28/2022 Per follow-up note:  07.14.22. S/W Rachel of Aetna @ 1-800-353-1232. Provider NPI# is on file for the provider and is participating effective 07/01/22 under the group and TIN#. PIN 5951375. Physical location is on file. Ref# 6100299498 - Ria Dee Bieren\nDCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Pending Coventry enrollment.  Coventry panel closed at this time.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Pending Coventry enrollment.  Coventry panel closed at this time.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","","","2023-09-08","Confirmed enrollment with all locations under WesTex. MS"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-05-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2022-05-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-19","TSCA and required documents emailed to spneast@sedgwickcms.com. Jen Videan"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2022-07-01","5951375","","2023-09-05","9/5/2023 Per email from Priscilla Albertine at MQA she received a roster confirming that provider is PAR and linked to group TIN/location effective 7/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-06-23","","","2022-08-10","8/10/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 6/23/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2022-09-01","","","2022-09-27","9/27/2022 Per follow-up note -  S/W Sophie of Cigna @ 1-800-882-4462. NPI# is on file for the provider and is participating effective 09/01/2022 under the group and TIN. Provider ID# 8228233. Physical location is on file.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Participating","Enrollment Complete","2022-06-23","","","2022-08-10","8/10/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 6/23/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2023-09-05","Emailed Alliance Provider Data Form to Michelle Killough at pswca,org requesting additional locations be added to Karen's profile. Jen Videan"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Provider Load","Provider Load","","","","2023-09-01","9/1/23 - Add new locations 4705 Briarwood Ave,  6950 Eastridge Rd.   and 6301 Andrews Hwy. DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2022-05-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/1/2022.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Karen Ward, NP-C, CNOR, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete","2017-05-01","1598976011","","2020-06-25",""]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Mutual","Participating","Enrollment Complete","2020-06-01","","","2020-10-06","10/6/2020 Received recredentialing approval notice and forwarded to Client for their files. Kimberly Frazier"]
["Stephen P Dodd, PA-C",1598976011,"46-0950925","TX","PE - 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-C",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Multiplan","Participating","Enrollment Complete","2015-04-16","1598976011","West Texas Physicians Alliance","2020-09-08","09/08/2020 - Rec'd response from the payer stating \"\n\nNetwork: Beech St, MPI, & PHCS\nNetwork Participation effective: Please see below\nContract Source Group contract through: Please see below\n\nStephen P Dodd, PA-C NPI: 1598976011\n5026 – West Texas Physicians Alliance – Beech St Eff Date 09/01/2009\n23655 – West Texas Physicians Alliance – MPI Eff Date 04/16/2015\n52669 – West Texas Physicians Alliance – PHCS Eff Date 01/21/2015\nAlso has an individual agreement under that TIN – Eff Date 08/07/2014\"\n\n- Stacey Hudak"]
["Nanette R Paredes, PA-C",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2018-10-03","1437175163","","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"]
["Nanette R Paredes, PA-C",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05","12235547","","2023-06-05","6/5/2023 - CAQH Reattested by Data Services Team - kavello"]
["Nanette R Paredes, PA-C",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Nanette R Paredes, PA-C",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2018-11-20","1437175163","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 11/20/2018 – Archie Candiasan"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2023-05-23","5.23.23 Plan pends Multiplan enrollment. ABoles"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","Galaxy Health","Participating","Enrollment Complete","2010-04-16","1619213386","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of 4/16/2010. – Jerha Gayorgor"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","First Health Coventry","Participating","Enrollment Complete","2020-02-01","1609797","","2020-03-20","03/02/2020 - Rec'd email fromt he payer confirming that this provider is effective with this payer under provider ID# 1609797 - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Omni PPO","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-29","06/29/2020 - IMS is PAR, therefore this payer is also effective  - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1184727562","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with PPO only products with this TIN/Service Location- Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","PE - 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","","Multiplan","Participating","Enrollment Complete","2014-06-04","1184727562","West Texas Physicians Alliance","2020-07-06","07/06/2020 - Rec'd email from the payer stating: \n\"Thank you for contacting our Service Department at Multiplan and Beech Street. Here is the following information we have on file for Johnson, Premila:\n\nNetwork:  MPI\nNetwork Participation effective: 09/01/2012 Contract Source Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech Street\nNetwork Participation effective: 06/04/2014 Contract Source Group contract through: West Texas Physicians Alliance\n\nIf any demographic information needs to be updated, please fax the information to our Registrar Department at (781) 487-8273 or email Registrar@MultiPlan.com.\" - Stacey Hudak"]
["Premila L S Johnson, MD",1184727562,"90-0858471","TX","","Aetna","Participating","Enrollment Complete","2007-01-01","1184727562","","2020-03-26","3/26/2020--SW Sandra of Aetna @ 800-353-1232. NPI is on file for the provider and is participating effective 1/1/2007 under group and TIN. DIRECT CONTRAC with Aetna. Physical location is on file. Call ref# 5195894813.\ntisha rader"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1437356730","","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"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2021-12-01","","","2021-12-07","12/7/2021 Rcvd email from SuperiorDelegation that November delegation roster has been completed and providers are loaded under appropriate group TIN/locations effective 12/1/2021.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-09-01","9560591","","2021-09-03","9/3/2021 Received an email from pdmcogz@cigna.com confirming provider is participating under group Tax ID effective 9/1/2021 with assigned provider ID number 9560591. KFrazier"]
["Johnny L Flitton, PA-C",1437356730,"","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-06-29","1437356730","","2020-06-25","06/25/2020 - Verified this provider is participating with this group through payer portal. This group is NON NETWORKED, but this provider is certified - Stacey Hudak"]
["Johnny L Flitton, PA-C",1437356730,"","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","","","2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 7/18/2019.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2023-09-12","Emailed add location request to wwtxcontracts@texasmutual.com. Jen Videan"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2014-02-05","1437356730","","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"]
["Johnny L Flitton, PA-C",1437356730,"","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2019-11-01","1437356730","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Johnny L Flitton, PA-C",1437356730,"","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-15","TSCA and required documents emailed to spneast@sedgwickcms.com. Jen Videan"]
["Johnny L Flitton, PA-C",1437356730,"","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2023-09-15","TSCA and required documents emailed to spneast@sedgwickcms.com. Jen Videan"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-12-01","","","2021-12-14","12/14/2021 Per portal, provider linked to location as of 12/1/2021. Cbankston"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Johnny L Flitton, PA-C",1437356730,"","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2021-11-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 11/1/2021. DCannon"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2015-03-17","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 3/17/2015.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-11-01","","","2021-12-12","12/12/2021 Sent f/u email to Michelle Monroe at Galaxy to check status of November Delegated Roster load.  Per email response November Delegated Roster load has been completed and provider is PAR w/ group/location effective 11/1/2021.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2015-02-16","1437356730","","2020-06-25",""]
["Johnny L Flitton, PA-C",1437356730,"","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel closed at this time.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel closed at this time.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","tx","PE - WesTex Urgent Care, PLLC","Multiplan","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel closed at this time.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel closed at this time.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"","tx","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel closed at this time."]
["Johnny L Flitton, PA-C",1437356730,"","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2023-09-15","9/15/2023 Delegated roster submitted.  DCannon"]
["Johnny L Flitton, PA-C",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1437356730","","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"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-04-15","","","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 4/15/2020.   DCannon"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-04-19","","","2023-04-19","4/19/2023 CAQH reviewed and re-attested.  DCannon"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-11-01","1901814","","2020-12-17","12/17/2020 - Rcvd confirmation email from payor that credentialing has been completed.  CPID 1901814 effective 11/1/2020.  DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2020-01-01","1760501720","","2020-08-31","08/31/2020 - Moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Liberty Mutual","Participating","Enrollment Complete","2009-10-23","1760501720","752656723","2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","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","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-20","1760501720","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-20","1760501720","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","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","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1760501720","","2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1901802","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2008 PID # 1901802\ntisha rader"]
["Gerardo M Catalasan, MD",1760501720,"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."]
["Gerardo M Catalasan, MD",1760501720,"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"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","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","","USA PPO","Participating","Enrollment Complete","2009-10-23","1760501720","752656723","2020-08-26","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","1093937948","","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"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1093937948","","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"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1093937948","","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"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","1093937948","","2020-10-02","10/2/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","PE - 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: S","TX","","TriCare Standard","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: S","TX","PE - 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: P","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2009-07-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/1/2009.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","","Cigna","Participating","Enrollment Complete","2020-02-26","6493392","","2021-11-15","11/15/2021 Per f/u note S/W Steven of Cigna @ 800-882-4462. NPI# for the provider is on file  shows LINKED and  Par under the group and TIN#,  effective 2/26/2020 , the physical location is on file and the Provider ID is 6493392.   DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: S","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","","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: P","TX","","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: S","TX","PE - Premier Family Care, Inc","Sedgwick","Participating","Enrollment Complete","2009-10-23","","","2020-09-09","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723: P","TX","","Medicaid","Participating","Enrollment Complete","2008-11-01","194906703","079837301","2021-02-08","2/8/2021 - Per f/u notes provider is participating at location  and under TIN effective 11/1/2008 TIP # 194906703.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2020-09-16","1K2721","0008AH","2020-12-17","12/17/2020 Received email of approval with assigned PTAN 1K2721, effective 9/16/2020. KFrazier"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","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","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2019-10-01","9469407","","2023-09-05","9/5/2023 Per email from Priscilla Albertine at MQA she received a roster confirming that provider is PAR and linked to group TIN/location effective 10/1/2019.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-03-01","1376723361","","2020-02-03","02/03/2020 - Confirmed that this provider is enrolled with a DIRECT CONTRACT EFF 3-1-2019 - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-06-19","","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/19/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2023-09-09","9/9/2023 Sent follow-up email to Cassandra Dunagon-Smith and Vanessa Christensen at Amerigroup to obtain status of provider.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Provider Load","Provider Load","","","","2023-09-02","9/2/2023 Add to new locations - 6301 Andrews Hwy,  4705 Briarwood Ave. and  6950 Eastridge Rd.   DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Provider Load","Provider Load","","","","2023-09-02","9/2/2023 Add to new locations - 6301 Andrews Hwy,  4705 Briarwood Ave. and  6950 Eastridge Rd.   DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Roster submitted.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2017-02-01","190978001","079837301","2021-02-08","2/8/2021 - Per f/u notes provider is participating at location  and under TIN effective 2/1/2017 TIP # 190978001.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel is closed at this time.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2017-09-01","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","United Health Care","In Process","Payor Follow Up","","","","2023-09-19","9/19/2023 Sent follow-up email to UHC to check status of August delegated roster provider loads.  PR-7623698.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-01","9/1/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","USA PPO","In Process","Application Submitted","","","","2023-08-15","8/15/2023 Roster submitted.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","In House Enrollment","2017-03-09","","","2023-09-01",""]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","In House Enrollment","2017-03-09","","","2023-09-01",""]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2017-11-28","1376723361","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.  Coventry panel is closed at this time.   DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Pending Info/Document","","","","2023-09-07","Emailed Priscilla and Neeraja for CAQH password. Need to make sure this location is on CAQH profile before submitting request to payor to add location. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Pending Info/Document","","","","2023-09-07","Emailed Priscilla and Neeraja for CAQH password. Need to make sure this location is on CAQH profile before submitting request to payor to add location. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.   Coventry panel closed at this time.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-09-02","9/2/2023 Pending Coventry enrollment.   Coventry panel closed at this time.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 8867748 DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Pending Info/Document","","","","2023-09-07","Emailed Priscilla and Neeraja for CAQH password. Need to make sure this location is on CAQH profile before submitting request to payor to add location. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - 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"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - 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","PE - Shylesh Ganta, MD, PA","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"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","United Health Care","Participating","Enrollment Complete","2020-01-01","1790972610","","2020-08-03","8/3/2020 - Emailed Tracy Diapolo and confirmed this provider is NOT with PriMed. That agreement has dissoled with UHC and the phone rep was incorrect in sharing this information. However, she confirmed the provider has been credentialed directly with UHC and all else is well. - Stacey Hudak"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1447415476","","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"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1447415476","","",""]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-04-15","","","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 4/15/2020.   DCannon"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-05-01","1447415476","","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"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2020-10-27","","","2020-12-01","12/1/2020 - Per f/u report Provider is on file and Par under the group and TIN# effective 10/27/2020.  DCannon"]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","First Health Coventry","Participating","Enrollment Complete","2011-02-01","2271235","","2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 2/1/2011 PID # 2271235\ntisha rader"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Galaxy Health","Participating","Enrollment Complete","2018-12-21","1194813709","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 12/21/2018 - Jesriel Segovia"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Humana","Participating","Enrollment Complete","2013-08-29","1194813709","","2020-06-30","6/30/2020 - Rec'd email spreasheet from payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/1/2020.   DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2017-11-29","1619982584","","2020-06-25",""]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-05-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/1/2020.   DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","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."]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-03-13","10740365","","2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Payor Follow Up","","","","2023-09-15","9/15/2023 Per Healthsmart provider portal provider is still not loaded under group TIN.  Will allow more time, check back in 2 weeks.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1619982584","","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"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","","United Health Care","Participating","Enrollment Complete","2017-10-31","3110523","","2020-07-28","7/28/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-03-01","","","2023-08-23",""]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2023-08-16","8/16/2023 Pending UHC enrollment.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Humana","In Process","Application Submitted","","","","2023-08-16","8/16/2023 Roster submitted to Humana to add provider to new location.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2017-08-01","365428YPVD","0008AH","2020-01-29","01/29/2020 - FOR PREMIER FAMILY confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30","1619982584","","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"]
["Adriana E Nur, MD",1619982584,"47-5554737","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"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Wellcare","Thru Other Payor","Pending Other Enrollment","","","","2023-08-16","8/16/2023 Pending Superior enrollment.  DCannon"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2023-07-01","","","2023-09-19","Provider is linked to this location. MS"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-11-30","","","2020-10-23","10/23/2020 Upon review of the self-service portal, provider is participating under group Tax ID and location effective 11/30/2018; therefore, this also confirms provider is certified as a non-network provider since it's required prior to participation. Kimberly Frazier"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","","Superior","Participating","Enrollment Complete","2020-08-01","1619982584","","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"]
["Adriana E Nur, MD",1619982584,"47-5554737","TX","","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."]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1376556019","","2020-07-14","07/14/2020 - Rec'd email back from the delegated team stating this provider has been linked to this TIN since 1-1-2017 **see the other Enrollment Complete line for details about specific products and when they became EFF** - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-05-05","","","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 5/5/2016.  DCannon"]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","In Process","Application Submitted","","1376556019","","2023-08-31","8/31/2023 Emailed Scott & White provider load spreadsheet to Velann Anderson to have provider loaded under group TIN/location.  DCannon"]
["Staton Awtrey, MD",1376556019,"75-2656723 : P","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2011-09-01","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care, Inc","BCBSTX","Participating","In House Enrollment","","","","2020-06-22","06/22/2020 - this enrollment is not performed by Symplr. Midland performs this in-house - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","In Process","Application Submitted","","1376556019","","2023-08-31","8/31/2023 Emailed Scott & White provider load spreadsheet to Velann Anderson to have provider loaded under group TIN/location.  DCannon"]
["Staton Awtrey, MD",1376556019,"75-2656723: S","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","1376556019","","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"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - 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","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2012-01-01","1558392779","","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"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - 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"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2002-04-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 4/1/2002.  DCannon"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2010-01-04","8L22951","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Juan C Gil, MD",1558392779,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2021-01-06","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1174241","","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"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-11-18","934064","320497","2020-03-10","03/10/2020 - Rec'd welcome letter from the payer - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Aetna","Participating","Enrollment Complete","2015-12-01","1881711778","","2020-04-23","04/23/2020--S/W JR of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 12/1/2015. Physical Location is on file. Provider ID #9826163. Call ref # 5234180829\ncopied note from spreadsheet-tisha rader"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Cigna","Participating","Enrollment Complete","2021-08-01","1881711778","","2022-08-09","8/9/2022 Rcvd email from Cigna that provider has been linked to group TIN/location effective 8/1/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Boon Chapman","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","","Caprock (CapStar)","Participating","Enrollment Complete","2021-08-02","1881711778","","2021-10-06","10/6/2021 Rcvd email from CapRock that monthly delegated roster has been loaded and the provider is PAR and linked to group TIN/location effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","1881711778","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Participating","Enrollment Complete","2010-07-25","284181901","","2023-09-18",""]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2010-07-14","1881711778","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","IMS","Participating","Enrollment Complete","2010-07-14","1881711778","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","USA PPO","Participating","Enrollment Complete","2021-01-26","1142937","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","BCBSTX","Participating","Enrollment Complete","2021-08-02","8CH649","","2021-11-19","11/19/21 Updated record from note made on 9/7/21. Michael Wolbert, MD is in network for the following HMO products, Blue Essentials HMO, Health Select, and Blue Advantage HMO. Provider ID, 8CH649, tied to TIN ending in 7379. The Lubbock satellite location has been added. Cbankston"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2010-07-14","1881711778","","2020-06-26",""]
["Michael P Wolbert, MD",1881711778,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","IMS","Participating","Enrollment Complete","2021-08-02","1881711778","","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 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Medicare","Participating","Enrollment Complete","2010-07-25","TXB111410","00608K","2020-05-04","05/04/2020 - was able to find/confirm PTAN through PECOS login - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"87-1671535","TX","PE - West Texas Allergy, Lubbock, PLLC","Omni PPO","Participating","Enrollment Complete","2021-08-02","1881711778","","2021-07-05","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 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2020-07-02","1881711778","","2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 7/2/2020.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Triwest VA","Enrollment on Hold","In House Enrollment","","","","2023-08-17",""]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Amerigroup","Participating","Enrollment Complete","2021-08-02","1881711778","","2022-11-28","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 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1881711778","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2021-08-01","9097673","","2021-09-01","9/1/2021 Received an email from pdmcogz@cigna.com confirming additional location has been updated for group with an effective date of 8/1/2021, and assigned provider ID 9097673. KFrazier"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","In Process","Pending Info/Document","","","","2023-08-22","Requested current driver's license for Dr. Wolbert. Sent request to Priscilla and Neeraja. Jen Videan"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","Amerigroup","Participating","Enrollment Complete","2020-07-02","1124350442","","2020-07-15","07/15/2020 - Rec'd welcome letter stating this provider is EFF 7-2-2020 with STAR, STAR+PLUS & Star Kids products - Stacey Hudak"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","Boon Chapman","Participating","Enrollment Complete","2016-05-16","1124350442","","2020-10-05","Enrollment thru PHCS"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2006-06-01","1487837712","West Texas Physicians Alliance","2020-09-28","09/28/2020 - Rec'd spreadsheet from the payer stating this provider is EFF under that West Texas Physicians Alliance delegation. This provider is networked with: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2010-04-15","","","2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 4-15-2010 under a DIRECT CONTRACT. Next recred is 1-26-2021 and this service location is linked to the provider - Stacey Hudak"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-02-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 2/1/2022.  DCannon"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2016-07-08","1437402278","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-07-01","","","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 7/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2021-09-06","","","2022-09-20","9/20/2021 Rcvd TMHP approval letter.  Provider is PAR and linked to group/location effective 9/6/2021.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2016-03-21","299111YPVD","0008AH","2021-11-15","11/15/2021 Per PECOS provider is PAR and linked to group PTAN/location.  PTAN # 2991117PVD - effective 3/21/2016.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-11-16","","","2022-12-28","12/28/2022 Per email received from Priscilla Albertine at MQA  she received updated from Joe Rodriguez provider is PAR and linked to group TIN/location effective 11/16/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-06-01","1437402278","","2020-02-20","02/20/2020 - Rec'd confirmation from the payer that this provider is EFF as of 6-1-2019 and linked to this locaiton - However, the provider is affiliated with a DELEGATED group. Cigna could not identify the delegated entity - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01","","","2023-07-03","07.03.2023 S/W Pam of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 07/01/2022. Provider ID 2876013 and No Recredentialing date. Service location is on file. Call ref#:686454 - Danico Gabriel Melendres"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-11-01","1262269","","2022-02-23","2/23/2022 Received email from pdmcogz@cigna.com, provider is par with location eff 11/1/2021. PID: 1262269. Cbankston"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-01-27","1437402278","Permian Basin Healthcare Network","2020-09-28","09/28/2020 - Rec'd spreadsheet from the payer stating this provider is EFF through: Permian Basin Healthcare Network with the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-07-01","","","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 7/1/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-01","","","2023-07-27","07.27.2023 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 11/01/2022. Provider ID 2906417. Service location is on file. Call ref#:709557. - Danico Gabriel Melendres"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-10-10","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","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"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-10-10","","","2022-12-31","12/31/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for October has been completed.  Provider is PAR and linked to group TIN effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-10-10","006200573","","2023-09-12","9/12/2023 Rcvd email from UHC that provider is PAR and linked to group TIN/location effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-10-10","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - 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"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Medicare","Participating","Enrollment Complete","2021-04-28","1T8899","1T8900","2021-09-15","9/9/2021 Received approval from Medicare that provider and group have been approved.  Group PTAN # 1T8900 and Individual Provider PTAN # 1T8899 - effective 4/28/2021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-04","8/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/12021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-08-04","8/4/2021 Rccvd email from Scott & White swhpdelegation@bswhealth.org that provider is PAR and linked to TIN/locations effective 6/1/2021.  DCannon"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2016-10-05","1619008141","","2020-02-12","2/12/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n03/20/2020 - Rec'd confirmation from Multiplan/Texas True Choice is EFF for this provider/service location. - stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","9223693","","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 9223693. KFrazier"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2016-10-05","1619008141","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01","1619008141","","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"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2016-10-01","1903184","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2016 PID # 1903184\ntisha rader"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","CAQH","Participating","In House Enrollment","2020-06-11","12334676","","2020-06-11","06/11/2020 - Provider did not supply CAQH login. Provider will maintain this info in-house - Stacey Hudak"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Cigna","Participating","Enrollment Complete","2021-06-01","6313275","","2021-09-13","9/13/2021 Received email from pdmcogz@cigna.com, Their  records indicate that your provider was credentialed as of 06/01/21 under the below tax ID with assigned provider ID 6313275. Cbankston"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","United Health Care","Participating","Enrollment Complete","2017-09-09","3517020","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-02-23",""]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2022-02-15","","","2022-05-05","5/5/2022 Rcvd email from Scott & White confirming that the February delegation roster has been completed and the provider are now loaded and PAR w/ group TIN/locations effective 2/15/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2021-12-31","","","2022-02-25","2/25/2022 Per Tricare portal, provider is linked to location eff 12/31/2021. Cbankston"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-10","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-10","","","2022-03-29","3/29/2022  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-10","","","2022-03-29","3/29/2022  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-10","","","2022-02-08","2/8/2022 Per email from Jamie Roberts @ Aetna provider is PAR and linked to group TIN/location effective 1/10/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Pending Other Enrollment","Pending Other Enrollment","","","","2022-03-07","3/7/2022 Pending Medicare enrollment.  Once enrolled in Medicare will move forward w/ TX Medicaid enrollment.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-02-01","","","2022-02-01","2/7/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 2/1/2022.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["Leela S Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-01-10","","","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 1/10/2022.  DCannon"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2016-01-01","1871782961","","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"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1871782961","","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"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-10-01","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 10/1/2020.  DCannon"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1053601344","","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"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31","1053601344","","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"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","","","2020-09-09","Confirmed provider is participating with PPO, H&W and GEN networks (GEN is behavioral health) (list of networks attached). Kimberly Frazier"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-29","1972816189","","2020-08-19","08/19/2020 - Rec'd response from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2019-07-30","1972816189","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1972816189","","",""]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology 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.\""]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","CAQH","Participating","CAQH Reattested","2023-03-06","14113335","","2023-03-06","3/6/2023 Rcvd email from Jack Waters that CAQH profile had been reviewed and re-attested.  DCannon"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2018-01-30","","","2021-08-06",""]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2018-01-03","","","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 1/3/2018.  DCannon"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2023-03-10","","","2023-03-10","3/10/2023 CAQH reviewed and reattested.  DCannon"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2017-11-27","P02027037","DU5783","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2018-07-31","","","2021-05-06","5/6/2021  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 7/31/2018.  DCannon"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective from 8/1/22"]
["Chelsea N Luebke (Sandridge), APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Panel Closed","Panel Closed","","","","2023-07-19","07/18/2023. 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"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Medicare","Participating","Enrollment Complete","2021-04-01","1N5324","IN5325","2021-04-12","4/12/2021 Upon review of PECOS, location has been added effective 4/1/2021 with assigned group PTAN 1N5325 and provider PTAN 1N5324. KFrazier"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-08-01","678418","519061","2020-04-27","04/27/2020 - Confirmed enrollment through PECOS Group enrollment - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","IMS","Participating","Enrollment Complete","2022-06-01","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Scott&White (First Care)","Participating","Enrollment Complete","2022-06-01","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","IMS","Participating","Enrollment Complete","2021-04-01","","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 4/1/2021. DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-07-11","1760860720","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provdier is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey HUdak"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-03-23","3/23/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records immediately upon receipt.  KFrazier"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","HealthSmart PPO","Participating","Enrollment Complete","2021-04-01","","","2021-06-03","6/1/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/1/2021.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Multiplan","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","PE - Midland Medicine PA","Amerigroup","Participating","Enrollment Complete","2021-06-03","","","2021-12-03","12/3/2021 Per Amerigroup roster received Joe Rodriguez provider is PAR under group TIN/location effective 6/3/2021.   DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","HealthSmart PPO","Participating","Enrollment Complete","2022-06-01","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Wellcare","Participating","Enrollment Complete","2022-06-01","","","2022-07-01","7/1/2022 Received June Monthly Validation roster from Superior and provider is PAR and linked effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine 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"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-03-01","1255614970","","2020-09-09","09/09/2020 - moved to completed status after reviewing last note - Stacey Hudak"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-08-24","552043ZV0W","519061","2020-04-20","04/20/2020 - confirmed EFF through group PECOS - Stacey Hudak"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-10-01","1255614970","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the PriMed delegation - Stacey Hudak"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - 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","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-10-01","9699508","5708963","2020-11-24","11/24/2020 - Per F/U Report provider is linked and participating in Network effective 10/01/2020 under the group and TIN#. Provider ID 9699508. Group ID 5708963.  DCannon"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1447412895","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-09-15","1447412895","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-08-01","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Rail Road Medicare","Participating","Enrollment Complete","2016-01-09"," P01708900","DW5495","2020-05-04","05/04/2020 - confirmed EFF info through payer portal - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Aetna","Participating","Enrollment Complete","2016-04-01","1447406137","","2020-03-24","3/24/2020--S/W Ian of Aetna @ 800-872-3862, rep advised to call 8003531232. Called 8003531232 and S/W Vanessa, provider NPI is on file for the provider and participating effective 4/1/16 under the group and TIN. Physical location is on file. Delegated with Primed Health network. Provider ID# 9536191. Call ref# 5192468082.\ntisha rader"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Medicaid","In House Enrollment","In House Enrollment","","","","2021-04-27","4/27/2021 Emailed Rebecca Pontaski with request to provide assigned TPI and effective date to close this out. KFrazier"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Cigna","Participating","Enrollment Complete","2019-09-01","8628903","","2020-07-16","7/16/2020 - Rec'd email from the payer stating \"Thank you for your submission. This is to confirm that your request has been completed.\" - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Rail Road Medicare","Participating","Enrollment Complete","2016-01-09"," P01708900","DW5495","2020-05-04","05/04/2020 - confirmed EFF info through payer portal - Stacey Hduak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Scott&White (First Care)","Participating","Enrollment Complete","2016-03-30","1447406137","","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 with this TIN/Service Location- Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2016-03-30","1447406137","","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 with this TIN/Service Location- Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Humana","Participating","Enrollment Complete","2016-03-10","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 3/10/2016.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Humana","Participating","Enrollment Complete","2016-03-10","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 3/10/2016.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","USA PPO","Participating","Enrollment Complete","2016-03-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","USA PPO","Participating","Enrollment Complete","2016-03-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Medicaid","In House Enrollment","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: S","TX","","Medicaid","In House Enrollment","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: P","TX","PE - Permian Digestive Disease Center PA","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","TriCare Standard","Participating","Enrollment Complete","2014-06-01","1447406137","","2020-04-06","04/06/2020 - Rec'd access to this group through payer portal. Rec'd confirmation that this provider is credentialed under this TIN and service location. THIS GROUP IS NON NETWORKED, so credentialing is not required. Only certification. - STacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","TriCare Standard","Participating","Enrollment Complete","2014-06-01","1447406137","","2020-04-06","04/06/2020 - Rec'd access to this group through payer portal. Rec'd confirmation that this provider is credentialed under this TIN and service location. THIS GROUP IS NON NETWORKED, so credentialing is not required. Only certification. - STacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","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: S","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: S","TX","PE - Permian Digestive Disease Center PA","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Omni PPO","Participating","Enrollment Complete","2020-09-01","1447406137","","2020-09-04","09/04/2020 - IMS is effective, therefore this payer line is also effective - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","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: S","TX","PE - Permian Digestive Disease Center PA","Aetna","Participating","Enrollment Complete","2019-09-01","1447406137","","2020-09-22","09/22/2020 - Rec'd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Aetna","Participating","Enrollment Complete","2019-09-01","1447406137","","2020-09-22","09/22/2020 - Rec'd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Cigna","Participating","Enrollment Complete","2016-02-05","1447406137","","2020-04-22","04/22/2020--SW Sharon of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 2/5/2016. Location is on file. Call ref# Sharon4202020.\ncopied note from spreadsheet-tisha rader"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Cigna","Participating","Enrollment Complete","2016-02-05","1447406137","","2020-04-22","04/22/2020--SW Sharon of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 2/5/2016. Location is on file. Call ref# Sharon4202020.\ncopied note from spreadsheet-tisha rader"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","First Health Coventry","Participating","Enrollment Complete","2016-07-01","1912442","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","First Health Coventry","Participating","Enrollment Complete","2016-07-01","1912442","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Superior","Participating","Enrollment Complete","2017-01-01","1447406137","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1447406137","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Medicare","Participating","Enrollment Complete","2016-01-09","363723ZS6M","472274","2020-05-04","05/04/2020 - confirmed provider is EFF thorugh PECOS for this provider - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Medicare","Participating","Enrollment Complete","2016-01-09","363723ZS6M","472274","2020-05-04","05/04/2020 - confirmed provider is EFF thorugh PECOS for this provider - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Humana","Participating","Enrollment Complete","2016-03-10","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Humana","Participating","Enrollment Complete","2016-03-10","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Amerigroup","Participating","Enrollment Complete","2016-03-30","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Amerigroup","Participating","Enrollment Complete","2016-03-30","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Boon Chapman","Participating","Enrollment Complete","2018-09-11","1447406137","","2020-10-05","Enrollment thru PHCS"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Boon Chapman","Participating","Enrollment Complete","2018-09-11","1447406137","","2020-10-05","Enrollment thru PHCS"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Multiplan","Participating","Enrollment Complete","2018-09-11","1447406137","Individual contract","2020-07-06","07/06/2020 - Rec'd email from the payer stating \"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Donepudi, Indira:\n\nNetwork:  MPI, PHCS, Savility, MPI WC, MPI Auto Network Participation effective: 09/11/2018 Contract Source Group contract through:  Individual contract\n\nIf any demographic information needs to be updated, please fax the information to our Registrar Department at (781) 487-8273 or email Registrar@MultiPlan.com.\" - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Multiplan","Participating","Enrollment Complete","2018-09-11","1447406137","Individual contract","2020-07-06","07/06/2020 - Rec'd email from the payer stating \"Thank you for contacting our Service Department at MultiPlan. Here is the following information we have on file for Donepudi, Indira:\n\nNetwork:  MPI, PHCS, Savility, MPI WC, MPI Auto Network Participation effective: 09/11/2018 Contract Source Group contract through:  Individual contract\n\nIf any demographic information needs to be updated, please fax the information to our Registrar Department at (781) 487-8273 or email Registrar@MultiPlan.com.\" - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","United Health Care","Participating","Enrollment Complete","2019-09-01","","","2020-11-10","11/10/20 - Rcvd confirmation email Ref # PR5483501 that provider has been linked and loaded effective 9/1/2019.  MPIN # 002945847"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","United Health Care","Participating","Enrollment Complete","2019-09-01","","","2020-11-10","11/10/20 - Rcvd confirmation email Ref # PR5483501 that provider has been linked and loaded effective 9/1/2019.  MPIN # 002945847"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","HealthSmart PPO","Participating","Enrollment Complete","2014-09-23","1447406137","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","HealthSmart PPO","Participating","Enrollment Complete","2014-09-23","1447406137","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Omni PPO","Participating","Enrollment Complete","2019-09-01","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: P","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-01","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: S","TX","PE - Permian Digestive Disease Center PA","IMS","Participating","Enrollment Complete","2019-09-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","IMS","Participating","Enrollment Complete","2019-09-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Galaxy Health","Participating","Enrollment Complete","2016-03-30","1447406137","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of 3/30/2016. – Jerha Gayorgor"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Galaxy Health","Participating","Enrollment Complete","2016-03-30","1447406137","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of 3/30/2016. – Jerha Gayorgor"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Amerigroup","Participating","Enrollment Complete","2018-05-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/3/2018.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Amerigroup","Participating","Enrollment Complete","2018-05-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/3/2018.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","PE - Permian Digestive Disease Center PA","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: S","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01","1447406137","","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"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","PE - Permian Digestive Disease Center PA","Scott&White (First Care)","Participating","Enrollment Complete","2016-03-30","1447406137","","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 with this TIN/Service Location- Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742: P","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2016-03-30","1447406137","","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 with this TIN/Service Location- Stacey Hudak"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Aetna","Participating","Enrollment Complete","2020-08-01","6418713","","2020-07-20","07/20/2020 - Rec'd email from the payer stating \"Welcome to the provider network effective 8/1/2020. Your Provider Identification Number (PIN) is: 6418713\" - Stacey HUdak"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Rail Road Medicare","Participating","Enrollment Complete","2014-06-10","P02417404","DO2096","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note and downloading EFF letter - Stacey Hudak"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","IMS","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","USA PPO","Participating","Enrollment Complete","2021-01-26","1312309","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records immediately upon receipt. KFrazier"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Cigna","Participating","Enrollment Complete","2020-09-15","5009460","","2020-09-18","09/18/2020 - Your effective date is 09/15/2020. Your provider identification number is 5009460.  - Stacey Hudak"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2020-04-03","","","2022-02-26","2/26/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/3/2020.  DCannon"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Medicare","Participating","Enrollment Complete","2014-06-10","363200ZH9T","00Y323","2020-03-10","03/10/2020 - Confimed through PECOS that this provider is linked to the corect group and EFF 6-10-2014 - Stacey Hudak"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","United Health Care","Participating","Enrollment Complete","2019-12-01","1750794749","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Omni PPO","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","IMS completed"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","CAQH","Participating","CAQH Reattested","2023-06-05","12740460","","2023-06-05","6/5/2023 - CAQH Reattested by Data Services - kavello"]
["Tiffany B Hansen, FNP-C",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete","2020-08-01","3524170","","2022-04-05","4/5/2022  Per First Health online provider directory provider is PAR and linked to group/locations  effective 8/1/2020.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1216979","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2021-09-28","","","2021-12-14","12/14/2021 Update from note made on 10/29/2021. Provider certified as of 9/28/2021. Cbankston"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1710180666","","2020-07-27","IMS complete"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-05-15","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/15/2020.   DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-05-15","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/15/2020.   DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1710180666","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1710180666","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-03-13","11714128","","2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-05-01","1447406137","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-08-24","372879ZV0W","519061","2020-04-20","04/20/2020 - Group PECOS enrollment confirrmed this group is listed as provider employer - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-12-01","2550759","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/1/2020.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13",""]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-09-15","1710180666","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-08-24","P01732063","DW7662","2020-10-09","10/9/2020 - Was able to confirm RR Medicare enrollment thorugh payer site - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2017-02-06","1710180666","","2020-08-31","08/31/2020 -moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1710180666","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","341080503","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is linked to group TPI 364596201 and this provider is affiliated with the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1710180666","","2020-07-02","7/2/2020 - Received email spreadsheet from the payor confirming that this provider is EFF ath this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2016-12-16","1710180666","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-09-15","1710180666","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 9-15-2016 at this service location under a DELEGATED ENTITY - but the payer couldnt identify who - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1710180666","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-12-15","1710180666","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicare enrollment completed in-house by MCHS.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2020-06-30","","","2022-06-01","6/1/2022 Provider is PAR w/ Multiplan effective 6/20/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-06-30","13484074","","2022-02-24","2/24/2022 Per follow-up note on 2/17/2022 -  Provider NPI# is on file for the provider and is participating effective 6/30/2020 under the group and TIN#. Provider ID 13484074. Physical location is on file. Call ref# 7917950.  - DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2020-06-30","","","2022-10-20","10/20/2022 Rcvd email from Priscilla Albertine at MQA with roster from Marcie Eckhart-Havens at Multiplan with confirmation that provider is PAR w/ Molina under group TIN/location effective 6/30/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-11-01","","","2020-09-14",""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2015-11-01","","","2020-09-14",""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2020-06-30","","","2022-10-20","10/20/2022 Rcvd email from Priscilla Albertine at MQA with roster from Marcie Eckhart-Havens at Multiplan with confirmation that provider is PAR w/ Molina under group TIN/location effective 6/30/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 07/18/2019.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 06/01/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-01-13","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 1/13/2020.   DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2021-02-13","5733523","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 2/13/2021 and assigned provider ID 5733523. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","5435845","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 5435845  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2019-09-01","7132451","","2020-08-04","8/4/2020 - moved to the completed status after getting an email from the payer stating this demo update has been completed - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-03-01","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 3/1/2022.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","7132451","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 7132451. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider has been added to the delegation at this TIN/service location - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-06-30","1348074","","2022-02-24","2/24/2022 Per follow-up note on 2/17/2022 - Provider NPI# is on file for the provider and is participating effective 6/30/2020 under the group and TIN#. Provider ID 13484074. Physical location is on file. Call ref# 7917950.  - DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-24","09/24/2020 - moved to completed status - PRIMED DELEGATION - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2020-01-13","","","2021-12-02","12/2/2021 Per Amerigroup roster received Joe Rodriguez for MCHS TIN 83-0358685 provider is PAR under group TIN/location effective 1/13/2020.   DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-02-12","","","2022-06-01","6/1/2022 Per Galaxy Health provider is PAR and linked to group TIN/location effective 2/12/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-11-15","5435845","7496529","2020-11-24","11/24/2020 - Per F/U report provider is linked and participating in Network effective 11/15/2015 under the group and TIN#. Provider ID 5435845. Group ID 7496529.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-14","","","2022-02-11","2/11/2022 Per Tricare portal, provider is linked to location as of 12.14.2021. Cbankston"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2020-11-15","5435845","7496529","2020-11-24","11/24/2020 - Per F/U report provider is linked and participating in Network effective 11/15/2015 under the group and TIN#. Provider ID 5435845. Group ID 7496529.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","Participating","Enrollment Complete","2020-09-01","349777802","165581301","2020-10-01","10/01/2020 - Rec'd emailed confirmation of enrollment from the clinic - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2021-02-13","5733523","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 2/13/2021 and assigned provider ID 5733523. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1639439185","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this provider has been added to the delegation at this TIN/service location - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 06/01/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","5435845","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 5435845  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-02-12","","","2022-06-01","6/1/2022 Per Galaxy Health provider is PAR and linked to group TIN/location effective 2/12/2020.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","Enrollment Complete","2020-09-01","1F3577","00304W","2020-10-14","10/14/2020 - Rec'd requested payer welcome letter from the clinic to update this payer line - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 07/18/2019.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicare enrollment completed in-house by MCHS.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2020-09-29","","","2020-10-23","10/23/2020 Upon review of the self-service portal provider is certified as a non-network provider under Group Tax ID and location is confirmed, effective 9/29/2020. Kimberly Frazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2016-09-16","03421665","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 9/16/2016;  PLUS - eff 9/16/2016, Star_Kids - eff 10/22/2015.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-11-03","11/3/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2019-09-01","7132451","","2020-08-04","8/4/2020 - rec'd email from the payer stating that this demo update has been completed.\" - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","Enrollment Complete","2020-09-01","1F3577","00304W","2020-10-14","10/14/2020 - Rec'd requested payer welcome letter from the clinic to update this payer line - Stacey Hudak"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-12-14","","","2022-02-11","2/10/2022 Per Tricare portal, provider is linked to location as of 12.14.2021. Cbankston"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2021-06-01","7132451","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 7132451. KFrazier"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04",""]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Irina Remsburg, MD",1639439185,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-04","8/4/2021 Medicaid enrollment completed in-house by MCHS.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-08-07","1659728855","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 8-7-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-06-14","1659728855","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-06-16","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","396567501","079837301","2020-01-29","01/29/2020 - Provider is linked to group. Provider is only PAR with traditional medicaid - stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-08-01","1659728855","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 8-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12","13681723","","2020-07-21","07/21/2020 - rec'd spreadsheet from the payer stating this provider is EFF with this TIN/service location as of 6-12-2019 under the WEST TEXAS PHYSICIANS ALLIANCE MDDO delegation - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-10-04","1659728855","","2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 10-4-2019 under a DIRECT CONTRACT. Next recred is 10-4-2022 and service location is on file and linked to provider - Stacey  Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-05-29","7093824","","2020-07-30",""]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-10-21","1659728855","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/19/2020 - rec'd email from the payer (Multiplan/Texas True Choice) confirming that this EFF info is true - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-08-07","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 8/7/2019.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-06-01","3278559","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR  6/1/2019 PID # 3278559\ntisha rader"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1659728855","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-03-13","14428752","","2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-31","1659728855","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-01-08","","","2021-03-31","3/31/2021 Confirmed provider certified at location via Humana-Military portal effective 1/8/2021.  DCannon"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-09-20","1659728855","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-20-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12","1659728855","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-06-14","1659728855","","2020-06-25",""]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12","1659728855","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-04-01","786679","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2021-01-07","","","2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 1/7/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2017-07-09","378408401","364596201","2020-12-31","12/31/2020 Confirmed provider is participating under group with assigned TPI 378408401, effective 7/9/2017. Next revalidation due 1/16/2023. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-03-01","3/1/2021 Rcvd confirmation that provider is participating with Healthsmart PPO effective 1/7/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-02-03","2/3/2021 - Rcvd confirmation email from payor stating that provider is participating and linked at location and TIN effective 1/7/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-11-01","003488587","","2021-05-12","5/12/2021 Recevied an email from United_Healthcare_Provider_Operations@uhc.com confirming provider has been loaded under group Tax ID and is now participating effective 11/1/2020 under PR-5736425 with assigned MPIN 003488587. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2020-11-01","0843337","","2021-02-26","2/26/2021 Received internal email of approval with an effective date of 11/1/2020 and assigned PID 0843337. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2021-02-01","","","2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2021-01-07","9896886","","2021-04-18","4/18/2021 Rcvd complete roster from Jamie Roberts <robertsj6@aetna.com> at Aetna listing provider as participating at TIN and locations.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","2023-01-18","01.18.2023: S/W Teresita of First Health @800-226-5116. Per rep, provider is participating, in network and linked under the group and TIN effective 12/01/2022. Provider ID# 2438435. Physical location is on file. Don't have payer#. Call Ref# 516478. - Mary Rose Acebedo"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2017-07-09","590902ZV0W","519061","2020-12-31","12/31/2020 Confirmed provider is participating under group with assigned PTAN 590902ZV0W effective 7/9/2017. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2019-08-09","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2022-11-15","","","2022-11-15","11/15/2022 CAQH reviewed and re-attested.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-07","1297078","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2021-01-07","","","2021-02-02","2/2/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2017-07-07","P01936022","DW7662","2020-12-31","12/31/2020 Confirmed provider is participating under group with RR PTAN P01936022, effective 7/7/2017. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-01-07","","","2021-02-02","2/2/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2017-08-01","","","2020-12-31","12/31/2020 Confirmed via self-service portal, provider is certified as non-network under group effective 08/01/2017. KFrazier"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 1/7/2021.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-03-24","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 03/24/2020.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-04","","","2023-05-04","5/4/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2023-05-04","","","2023-05-04","5/4/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2023-05-04","","","2023-05-04","5/4/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2022-06-01","1871028365","1275522864","2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-07-01","7352247","","2022-04-18","4/18/2022 Received email from pdmcogz@cigna.com, PID- 7352247. Request has been completed  under Cigna internal reference #  “W202204052277847 \" Eff 7.1.2022. Cbankston"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2022-11-04","11.04.2022: S/W Kourtney of First Health @ 800-226-5116. Provider NPI# is on file for the provider and contracted under the TIN effective 05/01/2022. Provider ID# 3556714. Physical location is on file. Payer# 73159. Ref# 458389. - Mary Rose Acebedo"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2022-04-11","008166209","","2022-09-06","9/6/2022 Per email received from UHC provider is PAR and linked to group TIN/locations effective 4/11/2022.  MPIN# 008166209. \n DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-04-11","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2022-11-20","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 11/20/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2022-04-11","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2022-04-11","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2022-04-11","","","2022-08-10","8/10/2022 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11","","","2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10","","","2022-07-12","7/12/2022 Rcvd email from First Care Scott and White confirmation provider is PAR and linked to group TIN effective 5/10/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder I am still waiting on both the provider and the group signatures for processing. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder I am still waiting on both the provider and the group signatures for processing. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder I am still waiting on both the provider and the group signatures for processing. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","In Process","Pending Info/Document","","","","2023-09-19","Sent reminder I am still waiting on both the provider and the group signatures for processing. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2016-09-22","1265872592","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 09/22/2016 under the group and TIN#. Provider is delegated to  PE - Midland Inpatient Medical Association. Physical location is on file. Call ref# 5309657469. - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Galaxy Health","Participating","Enrollment Complete","2022-01-01","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","United Health Care","Participating","Enrollment Complete","2022-05-13","","","2022-07-20","7/20/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/13/2022.   MPIN# 006290221.   DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1265872592","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-09-27","1265872592","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-03-08","6290221","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2023-06-05","13885700","","2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Ambetter","Participating","Enrollment Complete","2022-05-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Humana","Participating","Enrollment Complete","2022-01-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-01-23","P02003362","DW7662","2020-05-04","05/04/2020 - Verified and updated payer line - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Cigna","Participating","Enrollment Complete","2022-01-01","6345618","","2022-04-27","4/27/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 1/1/2022.  PID # 6345618.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Enrollment Complete","2022-01-10","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Multiplan","Participating","Enrollment Complete","2022-01-01","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-07-27","IMS complete"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Omni PPO","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Submitted","","","","2023-09-19","9/19/2023 Emailed demographic updated letter and W-9 to pdsdallas@aetna.com to add provider to group TIN/location.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Submitted","","","","2023-09-19","9/19/2023 Emailed demographic updated letter and W-9 to pdsdallas@aetna.com to add provider to group TIN/location.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Submitted","","","","2023-09-19","9/19/2023 Emailed demographic updated letter and W-9 to pdsdallas@aetna.com to add provider to group TIN/location.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Submitted","","","","2023-09-19","9/19/2023 Emailed demographic updated letter and W-9 to pdsdallas@aetna.com to add provider to group TIN/location.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-10-05","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 10/5/2016.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-02-15","1265872592","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 2-15-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2023-08-30","8/30/2022 Pending Medicare enrollment.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2023-08-30","8/30/2022 Pending Medicare enrollment.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2023-08-30","8/30/2022 Pending Medicare enrollment.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2023-08-30","8/30/2022 Pending Medicare enrollment.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellcare","Participating","Enrollment Complete","2022-05-01","","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Superior","Participating","Enrollment Complete","2022-05-01","","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-23","1265872592","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN/Service Location - Stacey Hudak\n\n**rec'd confirmation that this provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1265872592","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","363331502","364596201","2020-02-19","02/19/2020 - Per payer portal, this provider is effective with this group TPI 364596201 and linked to the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-01-23","512648ZV0W","519061","2020-04-20","04/20/2020 - confirmed provider EFF through PECOS group enrollment - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Wellmed","Participating","Enrollment Complete","2022-05-13","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/13/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1238661","","2021-01-01","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","In Process","Payor Follow Up","","","","2023-08-21","8/21/2023 Per USA PPO provider portal provider is still not loaded under group TIN/locations.  Will allow more time, check back in 2 weeks.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","IMS","Participating","Enrollment Complete","2022-01-01","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 1/1/2022. DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-08-23","8/23/2023 Sent email Scott & White swhpdelegation@BSWhealth.org to check status of provider.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-08-23","8/23/2023 Sent email Scott & White swhpdelegation@BSWhealth.org to check status of provider.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-08-23","8/23/2023 Sent email Scott & White swhpdelegation@BSWhealth.org to check status of provider.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","In Process","Payor Follow Up","","","","2023-08-23","8/23/2023 Sent email Scott & White swhpdelegation@BSWhealth.org to check status of provider.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1265872592","","2020-11-02","11/2/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1649713595","","2020-07-27","IMS  complete"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-11-17","P01787070","DW7662","2020-05-04","05/04/2020 - verified and moved to effective status - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-05-29","1649713595","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 5-29-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-12-15","1649713595","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1649713595","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312372","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1649713595","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2016-12-15","1649713595","","2020-04-30","04/30/2020 - confirmed this provider/service location are linked to TIN through payer portal - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1649713595","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-11-17","1649713595","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2021-03-01","367256001","364596201","2021-03-01","3/1/2021 Received nofication TMHP revalidation has been completed successfully and provider is due for revalidation 2/25/2026. KFrazier"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1649713595","","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"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-10-01","1649713595","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the primed roster - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1649713595","","",""]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-03-12","1649713595","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2017-02-23","1649713595","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) stating this provider is effective with Amerigroup at this service location. - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-08-01","1649713595","","2020-08-31","08/31/2020 -moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Jeremiah L Stewart",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-11-17","553519ZV0W","519061","2020-04-20","04/20/2020 - verified completed enrollment through group PECOS - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2017-05-14","P01880121","DW7662","2020-05-04","05/04/2020 - verified and moved to effective status - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2017-05-14","579253ZV0W","519061","2020-04-20","04/20/2020 -confirmed provider is EFF through group enrollment in PECOS - Stacey Hduak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Travelers WC","In House Enrollment","In House Enrollment","","","","2022-09-15","9/15/2022 Enrollment is now done in-house by Ventra Health for Midland Emergency Managers effective 8/1/2022.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2017-06-06","1013456649","","2020-06-05","06/05/2020 - Rec'd an email from the payer stating this provider is EFF - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-08-01","1013456649","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312317","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2022-12-15","3546231","","2023-03-06","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 12/15/2022. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3546231. Physical location is on file. - DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-02-01","1013456649","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 2-1-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2020-05-08","1013456649","","2020-06-09","06/09/2020 - S/W Nathan of Aetna @ 8003531232, provider NPI# is on file for the provider and is participating effective 05/08/2020 under the group and TIN#. Provider is direct contract with Aertna. Physical location is on file. Call ref# 5309689188. - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2017-05-17","372790101","364596201","2022-02-08","2/8/2022 Per TMHP web portal license has been updated.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2019-09-01","","","2020-11-06","11/6/2020 Received email from United_Healthcare_Provider_Operations@uhc.com confirming provider is loaded under Group Tax ID and location for reference number PR-5512953 and assigned internal MPIN 006569937. Kimberly Frazier"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2017-06-01","1013456649","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1013456649","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service locatin and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","IMS complete"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Gallagher","In House Enrollment","In House Enrollment","","","","2022-09-15","9/15/2022 Enrollment is now done in-house by Ventra Health for Midland Emergency Managers effective 8/1/2022.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2018-04-20","1013456649","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2019-01-01","1396930426","","2021-05-26","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"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-01-01","3382000","","2020-06-08","06/8/2020 - Rec'd email from the payer stating this provider/address is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-01-07","761311","0008AH","2020-04-27","04/27/2020 - Confirmed enrollment through GROUP PECOS enrollment - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31","0669817","","2021-07-06","7/6/2021 Received an email from PDMCOGZ@cigna.com confirming provider is participating under group Tax ID effective 3/31/2021, with assigned ID 0669817. KFrazier"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-05","1396930426","West Texas Physicians Alliance","2020-09-28","09/28/2020 - moved to completed status after receiving a spreadsheet from the payer stating this provider is EFF with West Texas Physicians Alliance under the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-05","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 4/5/2019.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019 - Jesriel Segovia"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1396930426","","2020-06-26",""]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-01-31","1396930426","","2020-04-23","04/23/2020--S/W Kim of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 1/31/2019. Physical Location is on file. Provider ID #9109842. Call ref # 5234162545\ncopied note from spreadsheet-tisha rader"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-01","","","2021-04-02","4/2/2021 Per Humana Military Portal provider is certified and linked to group TIN and location effective 5/1/2020.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2323463","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31","1396930426","","2020-03-20","03/20/2020 - Rec'd email from the payer (multiplan/true texas choice) stating this provider/service location is EFF with amerigroup - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","283737907","079837301","2020-01-29","01/29/2020 - found provider PAR through Medicaid portal. Provider is linked to the following plans: Texas Children's Health Plan - Harris, UnitedHealthcare Community Plan - Harris, UnitedHealthCare Community Plan - Harris - Mmp, Texas Children's Health Plan - Jefferson, UnitedHealthcare Community Plan - Jefferson, TRADITIONAL MEDICAID, Texas Children's Health Plan - Harris, Texas Children's Health Plan - Jefferson, Texas Children's Health Plan - MRSA Northeast, United Healthcare - Texas - Harris, United Healthcare - Texas - Jefferson, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-05-01","","","2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-11-01","","","2020-11-25","11/25/2020 -  Rcvd email confirmation that Oct monthly roster was processed and this provider was made effective with the requested eff date of 11/1/2020.  DCannon"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2019-04-04","1396930426","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01","2323463","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1497985188","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-25","1497985188","","2020-08-20","8/20/2020 - Rec'd spreadsheet from the payer stating this provider has been affiliated with PRIMED DELEGATED AGREEMENT under this TIN/Service Location. Provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Aetna","Participating","Enrollment Complete","2017-12-01","1497985188","","2020-04-23","04/23/2020--S/W JR of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 12/1/2017. Physical Location is on file. Provider ID #5424885. Call ref # 5234180829\ncopied note from spreadsheet-tisha rader"]

{"sheet":"TaxIDSearch","index":2,"n_rows":1443,"n_cols":11,"rows_kept":1443,"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"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2018-08-30",1790767119,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"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2018-10-01",1790767119,null,"2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",null,null,"2021-08-25","8/25/2021 Received an email from PDMCOGZ@cigna.com confirming provider is now participating under group Tax ID and location effective 3/31/2021 with assigned provider ID 6670877. KFrazier"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2018-09-01",1790767119,null,"2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 9-1-2018 with a DIRECT CONTRACT. The proper service location is in file - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2018-07-14",null,null,"2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2018-08-29",1790767119,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - rec'd confirmation from Multiplan/Texas True Choice that this is correct - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-07-01",679507,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2018-08-01",1046218,null,"2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 8/1/2018 PID # 1046218\ntisha rader"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,386238501,79837301,"2020-01-29","01/29/2020 - Found provider PAR through payer portal. This provider is linked to the following plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-08-01",1790767119,null,"2020-02-12","02/12/2020 - this provider has been confirmed to be effective through the payer portal. EFF 8-1-2018 THROUGH WEST TEXAS PHYSICIANS ALLIANCE DELEGATED PARTY - networked to MPI. - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-07-14",null,null,"2020-11-03","11/3/2020 Upon review of the self-service portal provider reflects as 'complete'. Kimberly Frazier"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1790767119,null,"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"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-08-28",1790767119,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-07-27",11483093,null,"2023-07-27","7/27/2023 Added new location to CAQH profile.  CAQH reviewed and re-attested.  DCannon"]
["Douglas J Colson, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-07-27",11483093,null,"2023-07-27","7/27/2023 Added new location to CAQH profile.  CAQH reviewed and re-attested.  DCannon"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2013-12-27",1023520830,463131679,"2020-08-18","Confirmed provider is participating under delegated agreement for PPO and H&W Networks (list of networks attached). Kim Frazier"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01",null,null,"2020-09-11"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2018-05-02",1023520830,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-20",null,null,"2021-03-24","3/24/2021 Confirmed provider is already certified as a non-network provider. KFrazier"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01",1023520830,null,"2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-09-01",1023520830,null,"2020-08-27","08/27/2020 - moved to completed status after reviewing the follow up complete note - Stacey Hudak"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-11-01",1023520830,null,"2020-08-27","08/27/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-11-10",null,null,"2021-09-14","9/14/2021 Per Tricare portal, provider is participating with TaxID as of 11/10/2020. Cbankston"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2020-07-21","07/21/20220 - Rec'd email confirmation that this name change has been completed. Signed into PECOS to verify - Stacey Hudak"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1023520830,null,"2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2018-03-19",382485601,79837301,"2023-05-10","5/10/2023 Rcvd TX Medicaid revalidation approval letter.  Provider is PAR and linked to group.  TPI # 1023520830 - effective 3/19/2018.  DCannon"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-06-15",1023520830,null,"2020-10-05","Enrolled thru PHCS"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-07-11",1023520830,null,"2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-05-30",1023520830,null,"2020-06-05","06/05/2020 - Rec'd email from payer stating this provider is EFF - Stacey Hudak"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-06-15",1023520830,"52669: West Texas Physicians Alliance Group Cntrct","2020-03-11","03/11/2020 - Rec'd email response from the payer stating provider is effective with different networks/effective dates as follows:\n\"Network:  MPI \nNetwork Participation effective: 10/01/2019 Group contract through: West Texas Physicians Alliance\n\nNetwork:  PHCS\nNetwork Participation effective: 06/15/2018 Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech St.\nNetwork Participation effective: 11/27/2019 Group contract through: West Texas Physicians Alliance\"\n\nAll are linked to group TIN - Stacey Hudak"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-10",14145595,null,"2023-05-10","5/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-06-29",1023520830,null,"2020-07-09","07/09/2020 - Rec'd welcome letter from Multiplan stating provider is covered for all governmental payers - Amerigroup is covered (STAR, Star Plus, Star Kids) - Stacey Hudak"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-05-19",12623755,null,"2021-08-05","7/26/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 5/19/2020 with assigned provider number 12623755. KFrazier"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01",1023520830,null,"2020-07-27","IMS is complete"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-09-01",1023520830,null,"2020-09-02","09/02/2020 - Rec'd email from the payer stating this providers name update from Brown to Reeves has been completed EFF 9-1-2020 - Stacey Hudak"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01",null,null,"2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Lori Ann Reeves","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2018-05-01",3128029,null,"2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 5/1/2018 PID # 3128029\ntisha rader"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-16",1639524861,"52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 4-16-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21",1639524861,null,"2020-06-25"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01",793339,"0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01",793339,"0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 793339.  DCannon"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-28",13859704,null,"2023-06-28","6/28/23 Confirmed updated DEA is present and added 4214 ste 102 to profile. -kavello"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1639524861,null,"2020-07-17","7/17/2020 - received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01",3041792,null,"2020-03-24","3/24/2020-received email with roster from payor stating provider PAR 5/1/2019 PID # 3041792\ntisha rader"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-03",1639524861,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31",1639524861,752656723,"2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21",1639524861,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"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-05-21",1639524861,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-16",null,null,"2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 4/16/2019.  DCannon"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31",1639524861,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,360348204,79837301,"2020-01-29","01/29/2020 - found provider through payer portal. Provider is linked to the following plans: TRADITIONAL MEDICAID, Texas Children's Health Plan - MRSA Northeast, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2017-06-26",1639524861,null,"2020-08-03","8/3/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-09-15",1639524861,null,"2020-09-22","09/22/2020 - Called 800-872-3862 but routed to Aetna Corporate Center and unable to reach live rep. Called Aetna @ 800-353-1232 S/W Mark. Provider NPI# is on file for the provider and is participating effective 09/15/2020 under the group and TIN#. Physical location is on file.Call Ref# 5560576876. - Archie Candiasan"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-15",1639524861,null,"2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2020-03-01",1639524861,null,"2021-05-26","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"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",2017791,null,"2021-08-04","8/4/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 3/31/2021 with assigned provider ID number 2017791. KFrazier"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-01-05",null,null,"2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31",1639524861,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3-19-2020 - Rec'd email from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Rachel K Longacre, FNP-C","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-27",null,null,"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, FNP-C","PE - Premier Family Care, Inc","Superior","Participating","Application Submitted","2019-08-01",1639524861,null,"2023-06-19","6/19/23 Roster submitted"]
["Madhavi Gadiraju, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-11-01",1932541406,null,"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","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-08",13876531,null,"2023-06-08","06/08/2023 - Added 4214 andrews Hwy, Ste 107 to practice locations and added Mandy Stone as cred contact- kavello"]
["Madhavi Gadiraju, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-08",13876531,null,"2023-06-08","06/08/2023 - Added 4214 andrews Hwy, Ste 107 to practice locations and added Mandy Stone as cred contact- kavello"]
["Madhavi Gadiraju, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-30",1932541406,null,"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","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01",null,null,"2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Madhavi Gadiraju, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-07-02",1932541406,null,"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","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"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","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-04-15",1932541406,null,"2020-07-30","7/30/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-09-30",1932541406,null,"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","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-07-20",null,null,"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","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01",804641,"0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01",804641,"0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-08-14",1932541406,null,"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","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-07-20",1932541406,"52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 7-20-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2019-05-01",397298601,79837301,"2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Madhavi Gadiraju, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12",1932541406,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"]
["Madhavi Gadiraju, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01",1932541406,null,"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","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-01",1932541406,null,"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","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12",1932541406,null,"2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Madhavi Gadiraju, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-05-01",1932541406,null,"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","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-30",1932541406,null,"2020-06-25"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-08-26",1811423981,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26",1811423981,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"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-07-01",1811423981,null,"2020-09-09","09/09/2020 - moved to completed status after reviewing last note - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-08-30",1811423981,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - rec'd email from the payer Multiplan/Texas True Choie stating that this effective info is true - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-04-07",1811423981,null,"2020-07-20","07/20/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-26",1811423981,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12",1811423981,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-08-30",1811423981,752656723,"2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-01-01",null,null,"2020-10-30","10/30/2020 Provider is certified as non-network effective 1/1/2019, as she is currently participating under group Tax ID and location is being updated. Kimberly Frazier"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1811423981,null,"2020-07-19","7/19/2020 - Received email spredsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-06-01",1811423981,null,"2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 4/1/2022.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-08-26",1811423981,null,"2020-06-25"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-06-15",6103957,null,"2020-06-08","06/08/2020 - Rec'd email from the payer stating this provider is PAR with the network effective 6/15/2020. Your Provider Identification Number (PIN) is: 6103957 - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-10-01",1811423981,null,"2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-06-01",805590,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-10-23",null,null,"2020-12-04","12/4/2020 Upon review of self-service portal provider is now participating under Group Tax ID and location. KFrazier"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-04-28",14074150,null,"2023-04-28","4/28/2023 CAQH reviewed and re-attested.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-07-01",null,null,"2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/1/2020.  DCannon"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-06-01",6730214,null,"2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,397315801,79837301,"2020-01-29","01/29/2020 - found provider through payer portal. Provider is linked to these plans: FirstCare - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, FirstCare - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-08-01",3304172,null,"2020-03-24","3/24/2020-receieved email with roster from payor stating provider PAR 8/1/2019 PID # 3304172\ntisha rader"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-09-30",null,null,"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 9/30/2019.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2020-07-21",null,null,"2021-05-26","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"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-15",null,null,"2020-08-25","Confirmed provider is participating under delegation effective 9/15/2019. Kimberly Frazier"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-11-08",null,null,"2021-11-30","11/30/2021 Checked portal and provide is added to location. Cbankston"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-15",null,null,"2020-08-25","Confirmed provider is participating under delegation effective 9/15/2019. Kimberly Frazier"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Application Submitted","2020-07-17",null,null,"2023-07-14","Jamie Thompson emailed July delegated roster to vanessa.christensen@amerigroup.com.         Jen Videan"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-09-26",null,null,"2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 9/26/2019.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-08-12",null,null,"2020-12-22","12/22/2020 Upon review of the Self-Service portal, provider is participating under group Tax ID, which confirmed provider is certified as non-network provider since that's a requirement before able to become a PAR provider. KFrazier"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2019-07-01",129062909,null,"2020-08-07","8/7/2020 - rec'd welcome letter from the clinic stating this provider is EFF and linked to TIN - Stacey Hudak"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Application Submitted","2019-07-01",null,null,"2023-07-14","7.14.23 Roster submitted ABoles"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-18",1073672994,null,"2020-09-24"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2019-09-18",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/18/2019.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-09-30",1073672994,"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 9-30-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01",1073672994,null,"2020-11-02","11/2/2020 - moved to completed status due to follow up note -Stacey Hudak"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-11-01",1073672994,null,"2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-07-01",823276,null,"2020-08-07","8/7/2020 - moved to completed status after getting welcome letter from the clinic. No effective date was listed - Stacey Hudak"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-09-01",null,null,"2020-12-09","12/9/2020 - Rcvd confirmation from payor that provider is now active and linked to this location.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-10",10606333,null,"2023-05-10","5/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",2740972,null,"2021-07-27","7/27/2021 Received an email from PDMCOGZ@cigna.com with confirmation of approval for participation effective 3/31/2021 with assigned provider ID 2740972. KFrazier"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-09-30",1073672994,752656723,"2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-08-23",null,null,"2021-03-15","3/15/2021 Rcvd email from Christelle Tchampo at Scott & White confirming provider is participating under TIN and at location effective 8/23/2019.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 6/1/2022.  DCannon"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2020-01-01",1073672994,null,"2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Richard E Winn, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Megan Casselman, NP-C","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-03-13",14530139,null,"2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Megan Casselman, NP-C","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1528619525,null,"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","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,403199901,79837301,"2020-01-29","01/29/2020 - Found provider through payer portal. Provider is par with Traditional Medicaid only - Stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1528619525,null,"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","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01",1528619525,null,"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","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-12-11",1528619525,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"]
["Megan Casselman, NP-C","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312274,null,"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","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-07-01",6345073,null,"2020-07-10","07/10/2020 - Rec'd EFF email from the payer stating \"Welcome to the provider network effective 7/1/2020. Your Provider Identification Number (PIN) is: 6345073\" - Stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-10-01",869041,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-10-01",1528619525,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01",1528619525,null,"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","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-01-01",9832854,null,"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","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01",1528619525,null,"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","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01",null,null,"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","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-01",1528619525,null,"2020-07-27","IMS complete"]
["Megan Casselman, NP-C","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"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","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-12-30",null,null,"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","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-01",1528619525,null,"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","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-04-01",1528619525,null,"2020-09-24","09/24/2020 - moved to completed after reviewing follow up complete - Stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-12-11",13706552,null,"2020-07-21","07/21/2020 - Rec'd spreadsheet from the payer stating this provider/TIN/service location are PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated  - Stacey Hudak"]
["Megan Casselman, NP-C","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-12-30",1528619525,null,"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","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-12-13",1528619525,"52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 12-13-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28",null,null,"2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28",null,null,"2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023 - CAQH Reattested by Data Services - kavello"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023 - CAQH Reattested by Data Services - kavello"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"2022-09-15","9/15/2022 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10",8909854,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-03-10",8909854,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28",1922658319,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-28",1922658319,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15",null,null,"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 Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Multiplan","In Process","Payor Follow Up",null,null,null,"2023-07-13","Full Roster requested with monthly submission to resolve outstanding providers. ABoles"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","Multiplan","In Process","Payor Follow Up",null,null,null,"2023-07-13","Full Roster requested with monthly submission to resolve outstanding providers. ABoles"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05",null,null,"2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa Saldana, APRN-FNP-BC","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05",null,null,"2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-12-01",null,null,"2020-12-07","12/7/21020 - Rcvd confirmation email from Superior that provider has been loaded effective 12/1/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-10-13",13747034,null,"2020-12-23","12/23/2020 - Confirmed with HealthSmart that provider has been loaded effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312370,null,"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"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01",403920802,null,"2021-01-20","1/20/2021 Upon review of the TMHP portal, provider has been approved and issued TPI 403920802 under Group Tax ID/TPI. KFrazier"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-10-15",null,null,"2020-11-20","11/20/20 - Rcvd confirmation email from UHC confirming enrollment at this location.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-12-24",null,null,"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","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-10-01","1J2798","0008AH","2020-11-18","11/18/2020 - Rcvd notification from Novitas that Change of Information app has been approved.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01",null,null,"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"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-01",null,null,"2020-10-09","10/9/2020 Confirmed provider is certified as a non-network provider with TriCare East. Kimberly Frazier"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-12",null,null,"2021-03-18","3/18/2021 Received email from BSWHPEXPEDITES@BSWHealth.org confirming provider has been approved and is participating under group effective 3/12/3021. KFrazier"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-02-09",1299432,null,"2021-02-20","2/20/2021 - Rcvd email from Cigna that provider has been approved effective 2/09/2021 PIN # 1299432.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2020-10-13",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2020-10-13",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2021-12-01",3873524,null,"2022-03-23","3/23/2022 Per follow-up note - 03.10.2022.S/W Lania of Boon Chapman @ 800-950-7040. Provider NPI# is on file  and is participating effective 12/1/2021 under the group and TIN #. Provider ID#3873524.  Physical location is on file.Call ref# 7943427.- DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",14485629,null,"2023-07-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-04-01",null,null,"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"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-10-13",null,null,"2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-10-13",null,null,"2021-08-06","8/6/2021 Rcvd confirmation from Caprock that provider is par and linked to TIN/locations effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-10-13",3546328,null,"2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 10/13/2020.  PID # 3546238.  DCannon"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-05-04",null,null,"2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/4/2020.  DCannon"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-05-08",1306827266,null,"2020-08-14","8/14/2020 - Rec'd email response from the payer to verify that this provider is effective - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["James D Richardson, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-04-09",408517701,79837301,"2020-09-17","09/17/2020 - address added to medicare. address successfully added to TMHP group and as of today, the address has been linked to this providers account. - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-02-14",1306827266,"52669 - West Texas Physicians Alliance","2020-08-13","8/13/2020 - Rec'd email response from the payer stating \"The MultiPlan / PHCS Network Application for Richardson, James is complete.\n\nNetwork participation became effective as of 02/14/2020 with PHCS. The provider’s network participation is through 23655 - West Texas Physicians Alliance contract.\n\nNetwork participation became effective as of 02/12/2020 with MPI. The provider’s network participation is through 5026 - West Texas Physicians Alliance contract.\n\nNetwork participation became effective as of 02/14/2020 with MPI. The provider’s network participation is through 52669 - West Texas Physicians Alliance contract.\"  - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01",1306827266,null,"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"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["James D Richardson, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-01-24",937962,"0008AH","2020-03-04","03/04/2020 - rec'd welcome letter from the payer stating APPROVED eff 1-24-2020 and linked to group PTAN 0008AH - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1306827266,null,"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"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-02-14",1306827266,null,"2020-10-05","Enrollment thru PHCS"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-06-01",1306827266,null,"2020-05-01","05/01/2020 - Rec'd email from the payer stating \"Welcome to the provider network effective 6/1/2020.\" - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312349,null,"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"]
["James D Richardson, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-11",null,null,"2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating under Group Tax ID and correct location effective 6/11/2020. Kimberly Frazier"]
["James D Richardson, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-02-12",null,null,"2020-07-21","07/21/2020 - moved to completed status. Provider is enrolled with this TIN under WEST TEXAS PHYSICIANS ALLIANCE MDDO Delegated group - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-02-11",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/11/2020.  DCannon"]
["James D Richardson, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-02-04",1306827266,null,"2020-10-14","10/14/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01",1306827266,null,"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"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-05-05",6886462,null,"2020-05-06","05/06/2020 - Rec;d email from the payer stating \"Congratulations! Your application to participate in the Cigna network has been approved. Your effective date is 05/05/2020. Your provider identification number is? ?6886462.\" - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01",1306827266,null,"2020-07-27","IMS complete"]
["James D Richardson, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01",1306827266,null,"2020-10-01","10/01/2020 - moved to completed status after getting confirmation effective email from the payer - Stacey Hudak"]
["James D Richardson, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01",1306827266,null,"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"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-05-10",null,null,"2021-06-03","6/1/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-05-27",null,null,"2021-06-01","6/1/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group effective 5/27/2021 with assigned PIN number 8559734. KFrazier"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-05-10",null,null,"2021-06-03","6/3/2021 Rcvd email from Galaxy Health, Karen Avalos <kavalos@ghn.mci.com> that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-04-12",null,null,"2021-04-12","4/12/2021 Received email from Latisha Green at Latisha.Green@wpsic.com with written confirmation of certification approval under group Tax ID and location, effective 3/12/2021, and assigned TERV ID 752656723 79701 X012. KFrazier"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2021-06-01",null,null,"2021-06-03","6/3/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 6/1/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-10",null,null,"2023-05-10","5/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Kristie M Chu, MD","PE - 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","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-05-10",null,null,"2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 5/10/2021. DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-05-10",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-05-15",6198680,null,"2021-07-08","7/1/2021-S/W Mark of AETNA @ 8003531232, NPI# of the provider is on file and shows link and PAR under the group and TIN# effective 5/15/2021, physical location is on file. Provider ID is 6198680.   Rep confirmed that once provider is credentialed w/ Aetna automatically, provider is also credentialed w/First Health and Coventry. Call ref#6028239169. herminia Gilongos"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2021-05-10",null,null,"2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-04-12",null,null,"2021-11-03","11/3/2021 Per follow-up notes.  Provider NPI# is on file for the provider and is participating effective 04/12/2021 under the group and TIN#.   Physical location is on file. Call ref# 14226636.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2021-03-01",423389201,79837301,"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"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2021-06-21",7565313,null,"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 6/21/2021 and assigned provider ID 7565313. KFrazier"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2021-05-10",null,null,"2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 5/10/2021. DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-05-10",null,null,"2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2021-06-21",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/21/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2021-05-10",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-05-10",null,null,"2021-08-18","8/18/2021 Rcvd complete roster from S & W list provider has PAR and loaded under TIN/location effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2021-03-01","1P4382","0008AH","2021-05-20","5/20/2021 Rcvd Medicare approval letter from Candace Wynne.  PTAN # 1P4382 - effective 3/1/2021.  DCannon"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-05-10",null,null,"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"]
["Kristie M Chu, MD","PE - Premier Family Care, Inc","Alliance WC","Participating","Enrollment Complete","2021-05-21",null,null,"2021-12-02","12/2/21 Received email from michelle.killough@pswca.org, provider eff 05/21/2021 with Tax ID 75-2656723. Cbankston"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-12",null,null,"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","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-10-12",null,null,"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","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-09-17",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-04-01",9212791,null,"2021-05-07","5/7/2021 Called Aetna (888-632-3862 spoke with Andrea (call ref # 6017548190) she informed me that provider is PAR and linked to TIN/location effective 4/1/2021 PID 9212791.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-10-12","1H6228","0008AH","2020-11-23","11/23/2020 Provider has been approved under group PTAN and issued PTAN 1H6228 effective 10/12/2020. Kimberly Frazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2011-05-12",null,null,"2021-12-03","12/3/2021 Per Amerigroup roster received Joe Rodriguez provider is PAR under group TIN/location effective 5/12/2011.   DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-09-30",5196033,null,"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 9/30/2020 and assigned provider ID 5196033. KFrazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-04-01",9212791,null,"2021-05-07","5/7/2021 Called Aetna (888-632-3862 spoke with Andrea (call ref # 6017548190) she informed me that provider is PAR and linked to TIN/location effective 4/1/2021 PID 9212791.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Medicaid","In House Enrollment","In House Enrollment",null,null,null,"2021-08-12","8/12/2021 Per email received from Candace Wynne, she has submitted an application to add provider to location via the TMHP portal. KFrazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-12-14",null,null,"2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/14/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-09-17",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-12-01",null,null,"2020-12-22","12/22/2020 Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 12/1/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-10-12",null,null,"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","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-10-12",null,null,"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","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2020-09-17",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-11-08",null,null,"2021-11-30","11/30/21 Per Tricare portal, provider added to location. Cbankston"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-09-17",null,null,"2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2021-01-22","1/22/2021 - Rcvd email from Healthsmart Provider Services that provider is participating at location under TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-10-12","1H6228","0008AH","2020-10-30","10/30/2020 Confirmed provider is participating under group and assigned PTAN 1H6228 effective 10/12/2020. Kimberly Frazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2021-01-06","1/6/2020 - Rcvd confirmation from payor that provider load is complete.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2020-09-17",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2011-05-12",null,null,"2021-12-03","12/3/2021 Per Amerigroup roster received Joe Rodriguez provider is PAR under group TIN/location effective 5/12/2011.   DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2020-11-12","11/12/20 - Received email from payer 10/20/20 that provider has been loaded in their system as a participating provider effective 9/17/20.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312371,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-10-12",142128104,79837301,"2020-12-09","12/9/2020 Upon review of the TMHP group portal, provider has been approved and assigned TPI 142128104, and effective date is that of 10/12/2020. KFrazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2021-11-22",9212791,null,"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","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-09-17",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-12-14",null,null,"2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/14/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312371,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-10-12","1H6228","0008AH","2020-11-23","11/23/2020 Provider has been reassigned under group PTAN and assigned PTAN 1H6228 effective 10/12/2020. Kimberly Frazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-10-12",142128104,null,"2021-01-26","1/26/2021 - Per follow-up notes provider is participating and linked to address/TIN effective 10/12/2020; provider ID 142128104.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-11-01",null,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2011-05-12",null,null,"2021-12-03","12/3/2021 Per Amerigroup roster received Joe Rodriguez provider is PAR under group TIN/location effective 5/12/2011.   DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-09-17",null,null,"2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-11-01",null,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-04-19",null,null,"2023-04-19","4/19/2023 CAQH reviewed and re-attested.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01",null,null,"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","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01",null,null,"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","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01",null,null,"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","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01",null,null,"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","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01",null,null,"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","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-04-01",null,null,"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","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-12",null,null,"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","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01",null,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-09-17",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-09-17",null,null,"2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2020-09-17",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-09-17",null,null,"2020-11-12","11/12/20 - Received email from payer 10/20/20 that provider has been loaded in their system as a participating provider effective 9/17/20.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-05-20",null,null,"2021-08-03","8/3/2021 Per follow-up complete notes provider is PAR under the group and TIN# effective 5/20/2021 w/ no term date under this location. Provider ID is 75-2656723-79703-A004.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","First Health Coventry","In Process","Enrollment Complete",null,9212791,null,"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 3628663. Next recredentialing date is every 3 years (12/1/2025). No information for the payer#. -Kim Monique Fabian"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment",null,null,null,"2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-09-17",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-09-17",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01",null,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312371,null,"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"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-12",null,null,"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","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2020-09-17",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2020-09-17",null,null,"2020-11-12","11/12/20 - Received email from payer 10/20/20 that provider has been loaded in their system as a participating provider effective 9/17/20.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2020-09-17",null,null,"2020-11-12","11/12/20 - Received email from payer 10/20/20 that provider has been loaded in their system as a participating provider effective 9/17/20.  DCannon"]
["Leslie Michelle Rowland, FNP","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2021-11-22",9212791,null,"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","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-04-01",9212791,null,"2021-03-26","3/26/2021 Per follow-up call Atena SW Daniel Call Ref# 6008130068. He stated provider is in network with this address on file.  effective 4/1/2021.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-12",null,null,"2021-03-18","3/18/2021 Received email from BSWHPEXPEDITES@BSWHealth.org confirming provider has been approved and is participating under group effective 3/12/3021. KFrazier"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-02-12",6320597,null,"2021-02-20","2/20/2021 - Rcvd email from Cigna that provider has been approved effective 2/12/2021 PIN # 6320597.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Ni Adams, NP","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-03-02",null,null,"2022-03-09","3/9/2022 Per Tricare portal provider is certified and in network with location as of 3/2/2022. Cbankston"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-10-13",null,null,"2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 10/13/2020.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2020-10-13",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/13/2020.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-10-01","1K2965",null,"2020-12-17","12/17/2020 Received email of Medicare approval with assigned PTAN 1K2965 effective 10/1/2020. KFrazier"]
["Ni Adams, NP","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",null,null,null,"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, NP","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",14969540,null,"2023-06-05","6/5/2023 - CAQH Reattested by Data Services Team - kavello"]
["Ni Adams, NP","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1312232,null,"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"]
["Ni Adams, NP","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-10-13",null,null,"2021-01-22","1/22/2021 - Rcvd email from Healthsmart Provider Services that provider is participating at location under TIN effective 10/13/2020.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-10-13",null,null,"2021-04-07","4/7/2021 Rcvd roster from Mary Rodriguez 4/5/2021 listing provider as participating.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2020-10-13",null,null,"2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed 12/14/2020. DCannon"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-06-01",6615260,null,"2021-07-08","7/1/2021-S/W Jessie of AETNA @ 8003531232, NPI# of the provider is on file and shows link and PAR under the group and TIN# effective 6/1/2021, physical location is on file. Provider ID is 6615260.  As per Rep, Rep confirmed that once provider is credentialed w/ Aetna automatically, provider is also credentialed w/First Health and Coventry. Call ref#6028231587."]
["Ni Adams, NP","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-12-01",null,null,"2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-10-13",null,null,"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 10/13/2020.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01",null,null,"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"]
["Ni Adams, NP","PE - 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"]
["Ni Adams, NP","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-11-11",7533626,null,"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 11/11/2020 and assigned provider ID 7533626. KFrazier"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-10-13",null,null,"2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/13/2020.  DCannon"]
["Ni Adams, NP","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ni Adams, NP","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-03-02",null,null,"2022-03-09","3/9/2022 Per Tricare portal provider is certified and in network with location as of 3/2/2022. Cbankston"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-05-10",null,null,"2021-06-03","6/1/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023 - CAQH Reattested by Data Services Team - kavello"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-05-10",null,null,"2021-08-18","8/18/2021 Rcvd complete roster from S & W list provider has PAR and loaded under TIN/location effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-05-10",null,null,"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","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2021-11-01",3518705,null,"2022-02-18","2/18/2022 Received email from MadirajuP@aetna.com, provider is active with Coventry/First Health with an effective date of 11/01/2021. CPD ID 3518705. Cbankston"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-03-23",null,null,"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","PE - Premier Family Care, Inc","Medicaid","In House Enrollment","In House Enrollment","2021-07-01",1417309105,null,"2021-09-21","9/21/2021 Per email received from Candace Wynne she has submitted the TMHP application for provider.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2021-05-10",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-07-04",396521,null,"2021-07-06","6/24/2021 Received email from discovercigna@information.cigna.com confirming provider is participating under group Tax ID effective 7/4/2021 with assigned provider ID 0396521. KFrazier"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2021-05-10",null,null,"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","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-05-10",null,null,"2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 5/10/2021. DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-05-10",null,null,"2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-05-10",null,null,"2021-06-03","6/3/2021 Rcvd email from Galaxy Health, Karen Avalos <kavalos@ghn.mci.com> that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2021-05-10",null,null,"2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01",null,null,"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","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2021-05-10",null,null,"2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 5/10/2021. DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-05-10",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2021-07-01","1R4716","0008AH","2021-07-13","7/13/2021 Rcvd email from Medicare stating that providers Medicare application has been approved.  PTAN # 1R4716 - effective 7/1/2021"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2021-05-10",null,null,"2021-06-03","6/3/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 6/1/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2021-07-01","Q00110005","CE1588","2021-08-03","8/3/2021 Rcvd RR Medicare PTAN instantly after applying via RR Medicare website.  PTAN # Q00110005 effective 7/1/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2021-05-10",null,null,"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"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-05-06",null,null,"2022-05-19","5/19/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 5/6/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-03-04","Q00322545","CE1588","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322545 - effective 3/4/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-03-04","2E5656","0008AH","2022-06-13","6/13/2022 Rcvd Medicare approval letter.  PTAN # 2E5656 - effective 3/4/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-05-01",null,null,"2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022."]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2021-01-01",1588983134,null,"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","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-04-08",null,null,"2022-09-16","9/16/2022 Received approval letter from Scott & White.  Provider is PAR and linked to group TIN/location effective 4/8/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Judy J Jia, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11",null,null,"2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01",2763424,null,"2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID # 2763424.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-05-09",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/9/2022.  DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-02-21",4120898,null,"2022-06-21","6/21/2022 - Per follow-up note - NPI# for the provider is on file, shows par under the group and TIN#, effective 2/21/2022, the physical location is on file and the Provider ID is 4120898.  Call ref # Camaria6142022. - DCannon"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11",6052910,null,"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"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Judy J Jia, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-06-01",5835766,null,"2022-05-18","5/18/2022 Rcvd email from Aetna that provider is PAR and linked to group TIN/locations effective 6/1/2022.  PID # 5835766.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11",5305986,null,"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# 005305986.   DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2018-08-01",1689985962,1275522864,"2022-07-14","7/14/2022 Per TMHP web portal provider is PAR and linked to group effective 8/1/2018.  TPI # 1689985962.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-05-01",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01",2701656,null,"2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID # 2701656.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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."]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-20",null,null,"2022-09-16","9/16/2022 Received approval letter from Scott & White.  Provider is PAR and linked to group TIN/location effective 5/20/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-07-01",5369983,null,"2022-06-19","6/19/2022 Per email received from Aetna provider is PAR and linked to group TIN effective 7/1/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-02-01","2B8822","0008AH","2022-04-01","4/1/2022 Rcvd Medicare approval letter.  PTAN# 2B8822 - effective 2/1/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","TriCare Standard","In Process","Application Resubmitted",null,null,null,"2023-05-24","Submitted add via online portal. Process should take 3-15 business days. MS"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-07-09",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/9/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-02-01","Q00267329","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267329 - effective 2/1/2022.  DCannon"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-02-01",9335065,null,"2022-04-05","4/5/2022 Received email from pdmcogz@cigna.com, provider is eff as of 2.1.2022. PID 9335065. Cbankston"]
["Joshuae G Gallardo, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-02-21","2B8668","0008AH","2022-04-01","4/1/2022 Rcvd Medicare approval letter.  PTAN# 2B8668 - effective 2/21/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2012-06-15",1619130929,null,"2022-08-01","8/1/2022 Per TMHP web portal provider is PAR and linked to group effective 6/15/2012.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-02-21","Q00267321","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267321 - effective 2/21/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-05-06",null,null,"2022-05-19","5/19/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 5/6/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-05-01",null,null,"2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"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","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11",null,null,"2022-09-24","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-03-02",null,null,"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  3/2/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11",3645447,null,"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","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-03-02",null,null,"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 3/2/2022. DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10",null,null,"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"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-03-02",null,null,"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 3/2/2022. DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-07-01",5587864,null,"2022-06-19","6/19/2022 Per email received from Aetna provider is PAR and linked to group TIN effective 7/1/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-07-03",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/3/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-02-21",9373023,null,"2022-03-30","3/30/2022 Received email from pdmcogz@cigna.com, provider is par as of 2/21/2022, PID: 9373023. This request has been completed under Cigna Internal Reference#: W202203222253423. Cbankston"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-03-02",null,null,"2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 3/10/2022.  DCannon"]
["Claude B Nguyen, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01",2582285,null,"2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID # 2582285.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-07-01",5154560,null,"2022-06-19","6/19/2022 Per email received from Aetna provider is PAR and linked to group TIN effective 7/1/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2000-10-29",1558343988,1275522864,"2022-07-14","7/14/2022 Per TMHP web portal provider is PAR and linked to group effective 10/29/2000.  TPI # 1558343988.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-05-06",null,null,"2022-05-19","5/19/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 5/6/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"2022-08-23","8/23/2022 Per email from Multiplan provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-23",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/23/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10",null,null,"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"]
["John H Ownby, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11",null,null,"2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-07-01",2359722,null,"2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 7/1/2022.  PID# 2359722  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"2022-08-30","8/30/2022 Received a roster from Priscilla Albertine at MQA that she received from Michelle Rodriguez.  Provider is PAR and linked to group TIN/locations effective 4/11/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John H Ownby, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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"]
["John H Ownby, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"2022-10-13","10/13/2022 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"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-02-21",9403276,null,"2022-08-19","8/19/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 2/21/2022.  PID# 9403276.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR w/ Ambetter and linked to group delegation roster effective 5/1/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"2022-09-13","9/13/2022 Per roster received from Multiplan provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"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","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-05-01",null,null,"2022-05-19","5/19/2022 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-02-21","Q00267339","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q0267339 - effective 2/21/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-02-21","2B8895","0008AH","2022-04-01","4/1/2022 Rcvd Medicare approval letter.  PTAN# 2B8895 - effective 2/21/2022.  DCannon"]
["John H Ownby, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11",2074110,null,"2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 4/11/2022.   MPIN# 002074110.   DCannon"]
["Kendra Cooper, APRN-FNP-BC","Premier","Omni PPO","Participating","Application Submitted","2022-05-09",null,null,"2023-06-19","6/19/23 Roster submitted"]
["Kendra Cooper, APRN-FNP-BC","Premier","Omni PPO","Participating","Application Submitted","2022-05-09",null,null,"2023-06-19","6/19/23 Roster submitted"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-10-01",null,null,"2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Ambetter","Participating","Enrollment Complete","2022-10-01",null,null,"2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-08-15",1548447899,null,"2022-09-07","9/7/2022 Per TMHP web portal provider is PAR and linked to group effective 8/15/2022.  TPI # 1548447899.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Medicaid","Participating","Enrollment Complete","2022-08-15",1548447899,null,"2022-09-07","9/7/2022 Per TMHP web portal provider is PAR and linked to group effective 8/15/2022.  TPI # 1548447899.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Vishnu S Brahmandam, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD",null,"Omni PPO","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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",null,"Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12",null,null,"2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2022-09-12",null,null,"2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD",null,"IMS","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up",null,null,null,"2023-05-19","Provider is not pulling on the online directory. I've emailed ipa@usamco.com for information. MS"]
["Vishnu S Brahmandam, MD",null,"USA PPO","In Process","Payor Follow Up",null,null,null,"2023-05-19","Provider is not pulling on the online directory. I've emailed ipa@usamco.com for information. MS"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-08-15",null,null,"2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/15/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"First Health Coventry","Participating","Enrollment Complete","2022-08-15",null,null,"2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/15/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-10-01",null,null,"2022-12-19","12/19/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Superior","Participating","Enrollment Complete","2022-10-01",null,null,"2022-12-19","12/19/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-12-17",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 12/17/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Wellmed","Participating","Enrollment Complete","2022-12-17",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 12/17/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-15","2H6458","0008AH","2022-08-25","8/25/2022 Per PECOS provider is PAR and linked to group/location effective 8/15/2022.  PTAN # 2H6458.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Medicare","Participating","Enrollment Complete","2022-08-15","2H6458","0008AH","2022-08-25","8/25/2022 Per PECOS provider is PAR and linked to group/location effective 8/15/2022.  PTAN # 2H6458.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-12-29",null,null,"2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Wellcare","Participating","Enrollment Complete","2022-12-29",null,null,"2022-12-29","12/29/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-08-25",null,null,"2022-09-06","9/6/2022 Rcvd certification approval letter from Tricare that provider is approved and certified for the State of Texas effective 8/25/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"TriCare Standard","Participating","Enrollment Complete","2022-08-25",null,null,"2022-09-06","9/6/2022 Rcvd certification approval letter from Tricare that provider is approved and certified for the State of Texas effective 8/25/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-09-12",3315195,null,"2022-11-01","11/1/2022 Rcvd email from UCH that provider load has been completed and provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"United Health Care","Participating","Enrollment Complete","2022-09-12",3315195,null,"2022-11-01","11/1/2022 Rcvd email from UCH that provider load has been completed and provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-08-15",9858576,null,"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"]
["Vishnu S Brahmandam, MD",null,"Aetna","Participating","Enrollment Complete","2022-08-15",9858576,null,"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"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-08-25",null,null,"2022-09-06","9/6/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 8/25/2022.    DCannon"]
["Vishnu S Brahmandam, MD",null,"Tricare Prime","Participating","Enrollment Complete","2022-08-25",null,null,"2022-09-06","9/6/2022 Per Tricare portal provider is PAR and linked to group TIN/locations effective 8/25/2022.    DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-15","Q00322555","CD1588","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322555 - effective 8/15/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Rail Road Medicare","Participating","Enrollment Complete","2022-08-15","Q00322555","CD1588","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322555 - effective 8/15/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-08",null,null,"2023-05-08","5/8/2023 CAQH re-attested by provider.  DCannon"]
["Vishnu S Brahmandam, MD",null,"CAQH","Participating","CAQH Reattested","2023-05-08",null,null,"2023-05-08","5/8/2023 CAQH re-attested by provider.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Multiplan","In Process","Payor Follow Up",null,null,null,"2023-07-13","Full Roster requested with monthly submission to resolve outstanding providers. ABoles"]
["Vishnu S Brahmandam, MD",null,"Multiplan","In Process","Payor Follow Up",null,null,null,"2023-07-13","Full Roster requested with monthly submission to resolve outstanding providers. ABoles"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-09-12",null,null,"2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Galaxy Health","Participating","Enrollment Complete","2022-09-12",null,null,"2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-22",null,null,"2023-03-08","3/8/2023 Per email received from Scott & White provider is PAR and linked to group TIN/location effective 9/23/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Scott&White (First Care)","Participating","Enrollment Complete","2022-09-22",null,null,"2023-03-08","3/8/2023 Per email received from Scott & White provider is PAR and linked to group TIN/location effective 9/23/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-08-15",6692236,null,"2022-10-11","10/11/2022 Per email from Cigna provider is PAR and linked to group TIN/location effective 8/15/2022.  PID# 6692236.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Cigna","Participating","Enrollment Complete","2022-08-15",6692236,null,"2022-10-11","10/11/2022 Per email from Cigna provider is PAR and linked to group TIN/location effective 8/15/2022.  PID# 6692236.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12",null,null,"2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for September is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Humana","Participating","Enrollment Complete","2022-09-12",null,null,"2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for September is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-08-11"]
["Vishnu S Brahmandam, MD",null,"Boon Chapman","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-08-11"]
["Vishnu S Brahmandam, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-11","10.11.2022 Per follow-up note -S/W Qjuana of Amerigroup @ 800-454-3730. Per rep, provider is showing as participating with an Effective date 09/12/2022 and link under the Group and TIN. Provider ID 14402887, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-165123663.  DCannon"]
["Vishnu S Brahmandam, MD",null,"Amerigroup","Participating","Enrollment Complete","2022-09-12",null,null,"2022-10-11","10.11.2022 Per follow-up note -S/W Qjuana of Amerigroup @ 800-454-3730. Per rep, provider is showing as participating with an Effective date 09/12/2022 and link under the Group and TIN. Provider ID 14402887, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-165123663.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-08-26",null,null,"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",null,"Scott&White (First Care)","Participating","Enrollment Complete","2022-08-26",null,null,"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","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-06-20",null,null,"2023-07-11","Received confirmation from Client. MS"]
["Christopher A Stack, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2022-06-20",null,null,"2023-07-11","Received confirmation from Client. MS"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-06-20",null,null,"2022-08-10","8/10/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/20/2022.    DCannon"]
["Christopher A Stack, MD",null,"United Health Care","Participating","Enrollment Complete","2022-06-20",null,null,"2022-08-10","8/10/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/20/2022.    DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Christopher A Stack, MD",null,"CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-06-20",null,null,"2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",null,"USA PPO","Participating","Enrollment Complete","2022-06-20",null,null,"2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-06-20",null,null,"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 6/20/2022.  DCannon"]
["Christopher A Stack, MD",null,"Humana","Participating","Enrollment Complete","2022-06-20",null,null,"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 6/20/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-06-20",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",null,"Boon Chapman","Participating","Enrollment Complete","2022-06-20",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01",null,null,"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",null,"Superior","Participating","Enrollment Complete","2022-08-01",null,null,"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","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-07-18",9368747,null,"2022-10-25","10/25/2022 Rcvd approval notification email from Cigna.  Provider is PAR and linked to group TIN/location effective 7/18/2022.  PID # 9368747.  DCannon"]
["Christopher A Stack, MD",null,"Cigna","Participating","Enrollment Complete","2022-07-18",9368747,null,"2022-10-25","10/25/2022 Rcvd approval notification email from Cigna.  Provider is PAR and linked to group TIN/location effective 7/18/2022.  PID # 9368747.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-07-18",1568704971,null,"2022-08-22","8/22/2022 Per TX Medicaid web portal, provider is PAR and linked to group effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD",null,"Medicaid","Participating","Enrollment Complete","2022-07-18",1568704971,null,"2022-08-22","8/22/2022 Per TX Medicaid web portal, provider is PAR and linked to group effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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"]
["Christopher A Stack, MD",null,"Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-09-22",null,null,"2022-10-04","10/4/2022 Rcvd Tricare approval letter stating that provider is now a Tricare-certified provider in Texas effective 9/22/2022.  DCannon"]
["Christopher A Stack, MD",null,"TriCare Standard","Participating","Enrollment Complete","2022-09-22",null,null,"2022-10-04","10/4/2022 Rcvd Tricare approval letter stating that provider is now a Tricare-certified provider in Texas effective 9/22/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-06-20",null,null,"2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 6/20/2022.   DCannon"]
["Christopher A Stack, MD",null,"IMS","Participating","Enrollment Complete","2022-06-20",null,null,"2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 6/20/2022.   DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-08-01",null,null,"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",null,"Wellcare","Participating","Enrollment Complete","2022-08-01",null,null,"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","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-06-20",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",null,"Multiplan","Participating","Enrollment Complete","2022-06-20",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-06-20",null,null,"2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",null,"Galaxy Health","Participating","Enrollment Complete","2022-06-20",null,null,"2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Christopher A Stack, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-07-18","2G1495","0008AH","2022-07-21","7/21/2022 Rcvd Medicare approval letter.  PTAN # 2G1495 - effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD",null,"Medicare","Participating","Enrollment Complete","2022-07-18","2G1495","0008AH","2022-07-21","7/21/2022 Rcvd Medicare approval letter.  PTAN # 2G1495 - effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-08-01",null,null,"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",null,"Ambetter","Participating","Enrollment Complete","2022-08-01",null,null,"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","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-12-01",null,null,"2022-12-02","12.02.2022 S/W Aaron of Aetna @ 800-353-1232. Per rep, provider is showing participating with an Effective date 12/01/2022 and link under the Group and TIN. Provider ID 6799298, Payer ID 60054 and Recredentialing date 11/18/2025. Service location is on file. Call ref#:6122321344. - Danico Gabriel Melendres\\"]
["Christopher A Stack, MD",null,"Aetna","Participating","Enrollment Complete","2022-12-01",null,null,"2022-12-02","12.02.2022 S/W Aaron of Aetna @ 800-353-1232. Per rep, provider is showing participating with an Effective date 12/01/2022 and link under the Group and TIN. Provider ID 6799298, Payer ID 60054 and Recredentialing date 11/18/2025. Service location is on file. Call ref#:6122321344. - Danico Gabriel Melendres\\"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-06-20",null,null,"2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 6/20/2022.   DCannon"]
["Christopher A Stack, MD",null,"Omni PPO","Participating","Enrollment Complete","2022-06-20",null,null,"2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for July has been completed.  Provider is PAR and linked to group TIN effective 6/20/2022.   DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",null,null,null,"2023-01-18","01.18.2023: S/W Kimora of First Health @800-226-5116. Per rep, provider is participating, in network and linked under the group and TIN effective 12/01/2022. Provider ID# 3162672. Physical location is on file. Don't have payer#. Unable to obtain call ref# since the rep transferred me to a different dept. - Mary Rose Acebedo"]
["Christopher A Stack, MD",null,"First Health Coventry","Participating","Enrollment Complete",null,null,null,"2023-01-18","01.18.2023: S/W Kimora of First Health @800-226-5116. Per rep, provider is participating, in network and linked under the group and TIN effective 12/01/2022. Provider ID# 3162672. Physical location is on file. Don't have payer#. Unable to obtain call ref# since the rep transferred me to a different dept. - Mary Rose Acebedo"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-07-18","Q00299482","CE1588","2022-07-28","7/28/2022 Rcvd RR Medicare approval letter.  PTAN # Q00299482 - effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD",null,"Rail Road Medicare","Participating","Enrollment Complete","2022-07-18","Q00299482","CE1588","2022-07-28","7/28/2022 Rcvd RR Medicare approval letter.  PTAN # Q00299482 - effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-06-20",null,null,"2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",null,"Amerigroup","Participating","Enrollment Complete","2022-06-20",null,null,"2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"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"]
["Christopher A Stack, MD",null,"Tricare Prime","Panel Closed","Panel Closed",null,null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01",null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-03-28",1366172579,null,"2023-05-18","5/18/2023 Rcvd TX Medicaid approval letter.  Provider is PAR and linked to group.  TPI # 1366172579- effective 3/28/2023.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2022-07-20","7/20/2022 Pending Multiplan enrollment.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-01-01",null,null,"2022-12-13","12/13/2022 Per email received from Priscilla Albertine at MQA provider is PAR and linked to group TIN/locations effective 1/1/2023.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-05-07","2H3685","0008AH","2022-08-18","8/18/2022 Rcvd Medicare approval letter.  PTAN # 2H3685 - effective 5/7/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12",null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-08-12",null,null,"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 8/12/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01",null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-08-12",null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-02-09",3357467,null,"2023-02-16","02.16.2023  Per follow-up note - S/W Stephanie of Cigna @ 1-800-882-4462. Per rep, provider is showing participating with an Effective date 02/09/2023 and link under the Group and TIN. Provider ID 3357467, No Payer ID and Recredentialing date 02/09/2026. Service location is on file.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01",null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-08-12",null,null,"2022-10-10","10/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/12/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-17",null,null,"2023-01-30","1/30/2023 Rcvd Tricare certification approval letter.  Provider is Tricare certified effective 1/17/2023.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Multiplan","In Process","Payor Follow Up",null,null,null,"2023-07-15","Full Roster requested with monthly submission to resolve outstanding providers. ABoles"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01",null,null,"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"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12",null,null,"2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-08-12",null,null,"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# 008166641.   DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12",null,null,"2022-11-04","11.04.2022 S/W Chealse of Amerigroup @ 800-454-3730. Per rep, provider is showing participating with an  Effective date 08/12/2022 and link under the Group and TIN. Provider ID 14387498, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-166745338. -Danico Gabriel Melendres"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-12-27",null,null,"2022-12-13","12/13/2022 Rcvd email from Scott & White that provider is PAR and linked to group TIN/locations effective 12/27/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","USA PPO","Provider Type Not Enrolled","Provider Type Not Enrolled",null,null,null,"2023-03-09","3/9/2023 Per email from LaNetrice Myart at USA PPO provider type - Registered Dietitians are not enrolled by USA PPO.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-05-07","Q00322576","CE1588","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322576 - effective 5/7/2022.  DCannon"]
["Hannah Heflin, RD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-08-12",null,null,"2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 8/12/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-02-01",null,null,"2023-03-23","3/23/2023 Rcvd  confirmation that provider is PAR in Superior Health plan under the group TIN effective 2/1/2023.   DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-11-28",null,null,"2023-01-20","1/20/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 11/28/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment",null,null,null,"2022-12-29"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up",null,null,null,"2023-06-09","6.9.23 sent follow up email to vyoung@humana.com ABoles"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-11-28",null,null,"2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 11/28/2022.   DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"2023-01-05","1/5/2023 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"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-04-19",null,null,"2023-04-19","4/19/2023 CAQH reviewed and re-attested.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-03-01","2O0411","0008AH","2023-01-18","1/18/2023 Rcvd Medicare approval letter.  Provider is PAR and linked to group/location effective 3/1/2023.  PTAN # 2O0411.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-01-01",null,null,"2023-07-26","07.26.2023 S/W Stacy of First Health @800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 01/01/2023. Provider ID 3538491. Service location is on file. Call ref#:708924. - Danico Gabriel Melendres"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-09-27",1285983155,null,"2023-02-25","2/25/2023 Per the TMHP web portal the provider is PAR and linked to group effective 9/27/2022. PID # 1285983155.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-03-07",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/7/2023.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-02-23",null,null,"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","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-11-28",null,null,"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 11/28/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-11-28",null,null,"2023-03-09","3/9/2023 Per email rcvd from Karen Avalos at Galaxy, January monthly roster has been completed.  Provider is PAR and linked to group effective 11/28/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Cigna","In Process","Payor Follow Up",null,null,null,"2023-07-26","07.26.2023 Verification request has been emailed  to intake_pdm@cigna.com to verify provider credentialing status. - Angel Grace Belleza"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-03-01",null,null,"2023-05-24"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-03-01",826647,null,"2023-03-06","03.06.2023 Per follow-up note -  provider is showing participating with an Effective date of 03/01/2023 and link under the Group and TIN. Provider ID 826647. Service location is on file.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-02-01",null,null,"2023-03-23","3/23/2023 Rcvd  confirmation that provider is PAR in Superior Health plan under the group TIN effective 2/1/2023.   DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-11-28",null,null,"2023-02-28","2/28/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 11/28/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-11-28",null,null,"2023-06-21","Rcvd effective date of 11/28/2022 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-02-01",null,null,"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","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-11-28",null,null,"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 11/28/2022.  MPIN# 007977253.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-11-28",null,null,"2023-02-16","2.16.2023  Per follow-up note - S/W Qjuana of Amerigroup @ 800-454-3730. Provider is on file and participating. Link under the group and TIN effective 11/28/2022. Location is on file. Provider ID is 15422622.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-11-28",null,null,"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"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-11-28",null,null,"2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 11/28/2022.   DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05",null,null,"2023-04-18","4/18/2023 Per Tricare portal provider is PAR and linked to group TIN/location effective 1/5/2023.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"2022-12-22","12/22/2022 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"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-03-28",1184341745]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-04-28",null,null,"2023-05-22","5/22/2023 Rcvd email from Caprock that May roster has been processed and provider is PAR w/ group effective 4/28/2023.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-04-28",null,null,"2023-07-13","Rep replied and confirmed enrollment and effective date. MS"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-04-28",null,null,"2023-07-13","Received confirmation from rep. eff 4/28/23. MS"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-10",null,null,"2023-03-08","3/8/2023 Received Tricare certification approval letter.  Provider is Tricare certified in the state of Texas effective 1/10/2023.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up",null,null,null,"2023-07-13","vyoung replied and stated she is no longer with Humana and provider a new email address to send requests to. ntxnm@humana.com.  A new request was sent to this address. MS"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to group delegated roster effective 6/1/2023.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-04-28",null,null,"2023-07-13","Received confirmation email from rep. MS"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-08-27",null,null,"2023-07-17","Received email confirmation of enrollment. MS"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","CAQH","Terminated","Terminated","2023-07-31",null,null,"2023-07-31","7/31/2023- Rcvd EM from Pricilla, \"Hilary Cosby, RD is leaving Premier Family Care, Inc. Her last day is August 11, 2023. We can stop pursuing her payor enrollment applications starting today.\" Could not update CAQH as login on file is invalid."]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment",null,null,null,"2022-12-22"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-04-28",null,null,"2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 4/28/2023.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-03-01",null,null,"2023-01-25","1/25/2023 Rcvd approval email from Aetna.  Provider is PAR w/ group TIN/Location effective 3/1/2023.  PIN # 8706961.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","First Health Coventry","In Process","PreApp/LOI Sent",null,null,null,"2023-07-13","Submitted online request to enroll provider with First Health.  45-60 day processing. MS"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Amerigroup","In Process","Payor Follow Up",null,null,null,"2023-07-13","Sent email to joe.rodriguez@amerigroup.com requesting update on status of delegated providers. MS"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2023-04-28",null,null,"2023-07-11","Received confirmation from Client. MS"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-11-28","Q00426832","CE1588","2023-05-22","5/22/2023 Rcvd RR Medicare approval letter.  Provider is PAR - PTAN # Q00426832 effective 11/28/2033.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-11-28","2N4110","0008AH","2023-01-05","1/5/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/location effective 11/28/2022.  PTAN # 2N4110.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-02-14",null,null,"2023-01-31","1/31/2023 Received email from Scott & White with approval letter.  Provider is PAR and linked to group TIN/location effective 2/14/2023.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to group delegated roster effective 6/1/2023.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-04-28",null,null,"2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 4/28/2023.  DCannon"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up",null,null,null,"2023-07-13","Emailed ipa@usamo.com to get status update for enrollment. MS"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Cigna","In Process","Payor Follow Up",null,null,null,"2023-07-26","07.26.2023 Verification request has been emailed  to intake_pdm@cigna.com to verify provider credentialing status. - Angel Grace Belleza"]
["Hilary Cosby, RD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to group delegated roster effective 6/1/2023.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Cigna","Participating","Enrollment Complete","2020-12-01",9800227,null,"2021-08-03","8/3/2021 Per follow-up notes provider is link and Par  under the group and TIN# effective 12/1/2020 the physical location is on file.  Provider ID is 9800227.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Aetna","Participating","Enrollment Complete","2021-04-01",null,null,"2021-06-28","6/28/2021 Received email response from aetnaproviderservices@aetna.com confirming provider is participating under group Tax ID and location effective 4/1/2021. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2021-01-07",null,null,"2021-04-01","2/2/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for January has been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Boon Chapman","Participating","Enrollment Complete","2021-01-07",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Coventry Workers Comp","In House Enrollment","In House Enrollment",null,null,null,"2022-09-15","9/15/2022 Enrollment is now done in-house by Ventra Health for Midland Emergency Managers effective 8/1/2022.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","TriCare Standard","In Process","Payor Follow Up",null,null,null,"2022-03-28","3/28/2022 Location pending in portal, allow more time. Cbankston"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2021-11-10",1103233,null,"2022-02-10","2/10/2022 Received email from dilikarA@aetna.com, provider enrollment is complete. Provider ID: 1103233 and Effective date is 11/01/2021. Cbankston"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Multiplan","Participating","Enrollment Complete","2021-01-07",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Coventry Workers Comp","Participating","Enrollment Complete","2021-08-01",null,null,"2021-10-08","10/8/21 Recevied email from CoventryProvider@cvty.us.com, provider effective 8/1/2021. Cbankston"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-05",null,null,"2021-04-22","4/22/2021 Rcvd roster from S&W and provider is participating and linked to TIN effective 03/5/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2020-12-01","Q00021661","CE1588","2021-02-09","2/9/2021 - Rcvd RR Medicare Welcome letter.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","First Health Coventry","Participating","Enrollment Complete","2020-12-01",1103233,null,"2022-05-11","5/11/2022 Per First Health website provider is PAR and linked to group TIN/location effective 12/1/2020.  PID # 1103233.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2021-01-07",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-01-07",null,null,"2021-04-01","4/1/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for January has been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Rail Road Medicare","Participating","Enrollment Complete","2020-12-01","Q00021661","CE1588","2021-06-25","6/24/2021 Provider is already enrolled with payor under Tax ID with asssigned RR PTAN Q00021661 effective 12/01/2020. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Galaxy Health","Participating","Enrollment Complete","2021-01-07",null,null,"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","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2021-03-01",null,null,"2021-03-08","3/8/2021 Rcvd email from Superior confirming that the providers are PAR and loaded under TIN/locations effective 3/1/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07",null,null,"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","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2002-04-01",null,null,"2021-04-09","4/9/2021 4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 4/1/2002.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-12-01","1L5835","00008AH","2021-01-29","1/29/2021 Received Medicare approval notice for provider's reassignment to group effective 12/1/2020 and assigned PTAN 1L5835. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07",null,null,"2021-06-03","6/1/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","United Health Care","Participating","Enrollment Complete","2021-05-18",2438204,null,"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 5/18/2021 and assigned provider ID 2438204. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-07",946236,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023 - CAQH Reattested by Data Services Team - kavello"]
["Lawrence A Wilson, MD","PE - City of Midland Health Department","CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023 - CAQH Reattested by Data Services Team - kavello"]
["Lawrence A Wilson, MD","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2023-06-05",null,null,"2023-06-05","6/5/2023 - CAQH Reattested by Data Services Team - kavello"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-01-07",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2021-05-18",null,null,"2021-09-01","9/1/2021 Email reponse: LAWRENCE WILSON was approved for credentialing 02/25/2021 for Texas.\nThe provider is linked and contracted to TX tin 752656723 effective 05/18/2021.\n  Additionally, if you are wanting the specific lines of business that the provider are linked to, this information is now in your LINK/My Practice Profile (https://www.uhcprovider.com/en/demographics-profiles-attestation/link-my-practice-profile.html). Please see the attached handout for more information.\n\nIf you have further questions regarding this system, please feel free to contact the LINK help desk (866-842-3278, option 1).\n\nPlease let us know if we can assist further.\n \nSincerely,\nKatherine Floyd\nUnitedHealthcare\nNetwork Management Resource Team (NMRT)\n\nCbankston"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-01-07",null,null,"2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 01/07/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","USA PPO","Participating","Enrollment Complete","2021-01-07",null,null,"2021-05-04","5/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-12-01",9800227,null,"2021-07-08","7/1/2021- S/W Natalie of Cigna @  8008824462, NPI# is on file for the provider, shows link and Par  under the group and TIN# effective 12/1/2020 the physical location is on file.  Provider ID is 9800227, No call ref#- Herminia Gilongos"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Alliance WC","Participating","Enrollment Complete","2021-03-19",null,null,"2021-06-28","6/28/2021 Received an email from Rep Michelle Killough at michelle.killough@pswca.org confirming provider is participating effective 3/19/2021 under group Tax ID. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Amerigroup","Participating","Enrollment Complete","2021-01-07",null,null,"2021-12-03","12/3/2021 Per Amerigroup roster received Joe Rodriguez provider is PAR under group TIN/location effective 1/7/2021.   DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Omni PPO","Participating","Enrollment Complete","2021-01-07",null,null,"2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Medicare","Participating","No Enrollment Required","2020-12-01","1L5835","0008AH","2021-03-19","3/19/2021 There is no requirement to add additional location since provider is currently assigned PTAN under group. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2021-01-07",null,null,"2022-04-05","4/5/2022 Rcvd email from Joe Rodriguez at Amerigroup confirming provider is PAR and linked to group TIN/location effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Superior","Participating","Enrollment Complete","2021-05-01",null,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01",null,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Humana","Participating","Enrollment Complete","2021-09-01",null,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","IMS","Participating","Enrollment Complete","2021-01-07",null,null,"2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-12-01","0429805-07","0798373-01","2021-03-12","3/12/2021 Received forwarded approval notice from Candace Wynne, and provider has been assigned TPI 0429805-07 effective 12/01/2020. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2007-03-15",7942472,null,"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"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07",null,null,"2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Lawrence A Wilson, MD","PE - Premier Intensive Cardiac Rehabilitation","Medicaid","In Process","Pending Other Enrollment",null,null,null,"2021-06-25","6/25/2021 Pending group location add approval with TMHP at this time, as we can only add one performing provider at a time when enrolling the group location. KFrazier"]
["Lawrence A Wilson, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-05",null,null,"2021-03-24","3/24/2021 Rcvd confirmation email from hpcredentialinggroup@BSWHealth.org that provider is participating with TIN and location effective 3/5/2021.  DCannon"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-06-01",null,null,"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"]
["Joseph J Shayeb, MD",null,"IMS","Participating","Enrollment Complete","2023-06-01",null,null,"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"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",null,null,null,"2023-06-21","Received COI application confirmation. Reference # 3231460484  MS"]
["Joseph J Shayeb, MD",null,"Medicare","Participating","Enrollment Complete",null,null,null,"2023-06-21","Received COI application confirmation. Reference # 3231460484  MS"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","USA PPO","In Process","Application Submitted",null,null,null,"2023-06-19","6/19/23 Roster submitted"]
["Joseph J Shayeb, MD",null,"USA PPO","In Process","Application Submitted",null,null,null,"2023-06-19","6/19/23 Roster submitted"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD",null,"Boon Chapman","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Rail Road Medicare","Pending Other Enrollment","Pending Medicare",null,null,null,"2023-05-18","5/18/2023 Pending Medicare.   Will enroll when Medicare is received.   DCannon"]
["Joseph J Shayeb, MD",null,"Rail Road Medicare","Pending Other Enrollment","Pending Medicare",null,null,null,"2023-05-18","5/18/2023 Pending Medicare.   Will enroll when Medicare is received.   DCannon"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-07-01",null,null,"2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Joseph J Shayeb, MD",null,"Superior","Participating","Enrollment Complete","2023-07-01",null,null,"2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Aetna","In Process","Payor Follow Up",null,null,null,"2023-07-26","07.26.2023 S/W Bella G of Aetna @ 1-800-353-1232, per rep provider was already link to TIN but loaded as out of network for Tax ID. Application received on 06/13/2023 and still in process (now on applying phase). Tracking # is T30372890. No additional doc needed, just allow more time. TAT for processing is 30 business days. Call ref# 6156992822.  -Babylen Borbon"]
["Joseph J Shayeb, MD",null,"Aetna","In Process","Payor Follow Up",null,null,null,"2023-07-26","07.26.2023 S/W Bella G of Aetna @ 1-800-353-1232, per rep provider was already link to TIN but loaded as out of network for Tax ID. Application received on 06/13/2023 and still in process (now on applying phase). Tracking # is T30372890. No additional doc needed, just allow more time. TAT for processing is 30 business days. Call ref# 6156992822.  -Babylen Borbon"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Wellmed","Thru Other Payor","Pending Other Enrollment",null,null,null,"2023-05-18","5/18/2023 Pending UHC enrollment.  DCannon"]
["Joseph J Shayeb, MD",null,"Wellmed","Thru Other Payor","Pending Other Enrollment",null,null,null,"2023-05-18","5/18/2023 Pending UHC enrollment.  DCannon"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","BCBSTX","In House Enrollment","In House Enrollment",null,null,null,"2023-05-18"]
["Joseph J Shayeb, MD",null,"BCBSTX","In House Enrollment","In House Enrollment",null,null,null,"2023-05-18"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","TriCare Standard","In Process","Payor Requested Additional Info",null,null,null,"2023-07-27","Providers status is in \"Action Needed\" As requested, I've sent a secure message to Tricare with the providers information to request what is needed to complete enrollment. MS"]
["Joseph J Shayeb, MD",null,"TriCare Standard","In Process","Payor Requested Additional Info",null,null,null,"2023-07-27","Providers status is in \"Action Needed\" As requested, I've sent a secure message to Tricare with the providers information to request what is needed to complete enrollment. MS"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Cigna","In Process","Payor Follow Up",null,null,null,"2023-07-26","07.26.2023:Verification request has been emailed  to intake_pdm@cigna.com to verify provider credentialing status.-Kim Joseph Casanova"]
["Joseph J Shayeb, MD",null,"Cigna","In Process","Payor Follow Up",null,null,null,"2023-07-26","07.26.2023:Verification request has been emailed  to intake_pdm@cigna.com to verify provider credentialing status.-Kim Joseph Casanova"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD",null,"Multiplan","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","United Health Care","In Process","Application Submitted",null,null,null,"2023-06-19","6/19/23 Roster submitted"]
["Joseph J Shayeb, MD",null,"United Health Care","In Process","Application Submitted",null,null,null,"2023-06-19","6/19/23 Roster submitted"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Medicaid","Pending Other Enrollment","Pending Medicare",null,null,null,"2023-05-18"]
["Joseph J Shayeb, MD",null,"Medicaid","Pending Other Enrollment","Pending Medicare",null,null,null,"2023-05-18"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-07-05",null,null,"2023-07-05","7/5/2023- confirmed all information is current and reattested - kavello"]
["Joseph J Shayeb, MD",null,"CAQH","Participating","CAQH Reattested","2023-07-05",null,null,"2023-07-05","7/5/2023- confirmed all information is current and reattested - kavello"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2023-05-18","5/18/2023 Pending Aetna enrollment."]
["Joseph J Shayeb, MD",null,"First Health Coventry","Pending Other Enrollment","Pending Other Enrollment",null,null,null,"2023-05-18","5/18/2023 Pending Aetna enrollment."]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Amerigroup","In Process","Application Submitted",null,null,null,"2023-06-19","6/19/23 Roster submitted"]
["Joseph J Shayeb, MD",null,"Amerigroup","In Process","Application Submitted",null,null,null,"2023-06-19","6/19/23 Roster submitted"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Application Submitted",null,null,null,"2023-06-20","Updates submitted with monthly roster. MS"]
["Joseph J Shayeb, MD",null,"HealthSmart PPO","In Process","Application Submitted",null,null,null,"2023-06-20","Updates submitted with monthly roster. MS"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"2023-05-18","5/18/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Joseph J Shayeb, MD",null,"Tricare Prime","Panel Closed","Panel Closed",null,null,null,"2023-05-18","5/18/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-07-01",null,null,"2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Joseph J Shayeb, MD",null,"Wellcare","Participating","Enrollment Complete","2023-07-01",null,null,"2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD",null,"Caprock (CapStar)","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment",null,null,null,"2023-05-18"]
["Joseph J Shayeb, MD",null,"Triwest VA","In House Enrollment","In House Enrollment",null,null,null,"2023-05-18"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-06-01",null,null,"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"]
["Joseph J Shayeb, MD",null,"Omni PPO","Participating","Enrollment Complete","2023-06-01",null,null,"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"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Humana","In Process","Application Submitted",null,null,null,"2023-06-19","6/19/23 Roster submitted"]
["Joseph J Shayeb, MD",null,"Humana","In Process","Application Submitted",null,null,null,"2023-06-19","6/19/23 Roster submitted"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-07-01",null,null,"2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Joseph J Shayeb, MD",null,"Ambetter","Participating","Enrollment Complete","2023-07-01",null,null,"2023-07-21","7/21/2023 Rcvd confirmation email from Superior that June delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 7/1/2023.  DCannon"]
["Joseph J Shayeb, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD",null,"Galaxy Health","Participating","Enrollment Complete","2023-06-01",null,null,"2023-07-20","7/20/2023 Per email received from Galaxy June delegated roster has been processed and provider is PAR and linked to group effective 6/1/2023.  DCannon"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01",1679568380,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-01",null,null,"2020-10-30","10/30/2020 Confirmed provider is certified as non-network under Tax ID and location. Kimberly Frazier"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-06-01","1D5510","0008AH","2020-06-23","06/23/2020 - Rec'd email from the payer stating this provider is EFF 6-1-2020 under PTAN 1D5510 - Stacey Hudak"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-10-01",4403006,null,"2020-09-08","09/08/2020 - Rec'd email from the payer stating \"Welcome to the provider network effective 10/1/2020. Your Provider Identification Number (PIN) is: 4403006\" - Stacey Hudak"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-04-01",1679568380,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"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 Foster, Jr, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-07-11",1679568380,null,"2020-08-24","8/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed",null,null,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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 W Foster, Jr, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-04",10773285,null,"2023-05-04","5/4/2023 CAQH reviewed and re-attested.  DCannon"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03",null,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2020-06-01","P02490186","CE1588","2020-08-28","08/28/2020 - found effective info through payer site - updated payer line - Stacey Hudak"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1679568380,null,"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 W Foster, Jr, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-09-01",1900818,null,"2020-12-17","12/17/2020 - Rcvd confirmation email from payor that credentialing has been completed.  CPID 1900818 effective 9/1/2020.  DCannon"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01",1679568380,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-04-22",null,null,"2021-06-29","6/29/2021 Rcvd roster from Multiplan confirming provider is PAR under TIN effective 4/22/2020.  DCannon"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-02-05",1679568380,null,"2021-02-11","2/11/2021 Received email of provider approval from BSWHPEXPEDITES@BSWHealth.org with an effective date of 2/5/2021 and asks to allow 3-4 weeks before submitting claims so they may complete the configuration of provider load in their system. KFrazier"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01",1679568380,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-04-22",null,null,"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 4/22/2020.  DCannon"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1679568380,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-08-16",1208794,null,"2021-08-17","8/17/2021 Received an email from discovercigna@information.cigna.com confirming provider is participating under group Tax ID effective 8/16/2021 with assigned provider identification number 1208794. KFrazier"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2020-04-01",1679568380,null,"2021-05-26","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"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",514205,null,"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"]
["John W Foster, Jr, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-08-03",137278111,79837301,"2020-08-14","8/14/2020 - Rec'd notification that this enrollment has been completed. I corrected the SS# and the clinic must have uploaded the signed deficiency letter to assist completion. - Stacey Hudak"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-03-30",12019639,null,"2023-03-30","3/30/2023 CAQH re-attested.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2011-03-03",1912100850,null,"2021-11-15","11/15/2021 Per confirm par statues note.   S/W Diana of Tricare @ 800-444-5445 Transferred to WPS Dept. S/w Maggie. Provider NPI# is on file for the provider and is participating effective 03/03/2011 under the group and TIN#.  No end date. Physical location is on file. Call ref# 14226448.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-10-29",3531211,null,"2022-03-09","3/9/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 10/29/2021.  PID # 3531211.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-10-29",1912100850,null,"2023-07-11","Received confirmation from Client. MS"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Medicaid","Enrollment Stopped","Enrollment Stopped","2020-03-15",121276305,79837301,"2020-07-15","07/15/2020 - Rec'd email from the clinic stating provider is terming on 6/25/2020.  - Stacey Hudak"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-04-03",null,null,"2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 4/3/2020.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2012-03-01",1448905,null,"2021-11-15","11/15/2021 Per Amerigroup roster provider is PAR and linked to group TIN/location effective 3/1/2012.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-02-01",1067924,null,"2023-07-26","07.26.2023 S/W Patricia of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 02/01/2023. Per rep, they are not allow to gave out the Provider ID. Service location is on file. Call ref#:708924. Called again then S/W Stacy of First Health @ 800-226-5116. Per rep, the provider's Provider ID is 1067924. Call ref#:708924. - Danico Gabriel Melendres"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2009-12-01","8L21655","0008AH","2021-11-15","11/15/2021 Per PECOS provider is PAR and linked to group PTAN/location.  PTAN 8L21655 effective 12/1/2009.  DCannon."]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2011-01-17",1912100850,null,"2021-11-15"," S/W Ella of Aetna @ 8003531232, NPI# for the provider is Linked and Par under group and TIN# effective 1/17/2011, the physical location is on file, Provider ID is 5175561. Call ref#6052978261."]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Multiplan","Enrollment Stopped","Enrollment Stopped","2016-07-13",1912100850,"52669: West Texas Physicians Alliance Group Cntrct","2020-07-15","07/15/2020 - Rec'd email from the clinic stating provider is terming on 6/25/2020.  - Stacey Hudak"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2020-04-03",null,null,"2021-12-03","12/3/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 4/3/2020.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Omni PPO","Enrollment Stopped","Enrollment Complete","2019-09-01",1912100850,null,"2020-07-27","IMS complete"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Dario Beltran, MD","PE - Premier Family Care, Inc","IMS","Enrollment Stopped","Enrollment Complete","2019-09-01",1922008234,null,"2020-07-27","07/27/2020 - enrollment was completed due to being submitted on July 2020 roster to the payer - Stacey Hduak"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Boon Chapman","Enrollment Stopped","Enrollment Stopped","2016-07-13",1912100850,null,"2020-07-15","07/15/2020 - Rec'd email from the clinic stating provider is terming on 6/25/2020.  - Stacey Hudak"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-13",null,null,"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"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Terminated","Enrollment Stopped","2016-07-06",1912100850,null,"2020-10-12"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Galaxy Health","Enrollment Stopped","Enrollment Stopped","2019-05-18",1912100850,null,"2020-07-15","07/15/2020 - Rec'd email from the clinic stating provider is terming on 6/25/2020.  - Stacey Hudak"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2021-12-01",1912100850,null,"2021-12-07","12/7/2021 Rcvd email from SuperiorDelegation that November delegation roster has been completed and providers are loaded under appropriate group TIN/locations effective 12/1/2021.  DCannon"]
["Dario Beltran, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",5102893,null,"2021-07-06","7/2/2021 Received email from PDMCOGZ@Cigna.com confirming provider is now participating under group Tax ID effective 3/31/2021 with provider ID 5102893. KFrazier"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,357539103,79837301,"2020-01-29","01/29/2020 - Found provider PAR through payer portal. Provider is linked to the group TPI 079837301 with the following plans: \nTRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-18",1952865057,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"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03",null,null,"2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 4/3/2020.  DCannon"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-08-26",null,null,"2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-10-07",1104229293,"52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - **FOR PREMIER FAMILY CARE TIN** Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 10-7-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-09-01",858626,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2019-12-02",1104229293,null,"2021-05-26","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"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-09-30",1291209,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-09-01",3309742,null,"2020-03-20","03/20/2020 - Rec'd email from the payer confirming this provider is effective under PID# 3309742  with this TIN - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2020-06-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 6/1/2020.  DCannon"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-09-01",1104229293,null,"2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1104229293,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-02-15",1104229293,null,"2020-04-23","04/23/2020--S/W Christine of Aetna @ 800-353-1232. Per rep the Provider is on file, linked & participating under the GRP & TIN effective 2/15/2020. Physical Location is on file. Provider ID #4170965. Call ref # 5234061830\ncopied note from spreadsheet-tisha rader"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-09-01",1104229293,null,"2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01",1104229293,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01",1104229293,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01",1104229293,null,"2020-07-27","IMS completed"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-10-02",null,null,"2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 10/2/2019.  DCannon"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-09-01","P02428347","CE1588","2020-08-28","08/28/2020 - moved to completed status after confirming EFF info through payer site - Stacey Hudak"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1104229293,null,"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"]
["Venus M Skeen, DNP","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-10-07",null,null,"2021-09-15","9/15/2021 Received roster from Multiplan listing provider as PAR under group TIN/location effective 10/7/2019.  DCannon"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01",1467745240,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"]
["Adenike T Esho, MD",null,"Caprock (CapStar)","Participating","Enrollment Complete","2016-05-01",1467745240,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"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-08-30",1467745240,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Also rec'd email confirmation from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Adenike T Esho, MD",null,"Amerigroup","Participating","Enrollment Complete","2019-08-30",1467745240,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Also rec'd email confirmation from Multiplan/Texas True Choice confirming that this EFF information is true - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-08-26",1467745240,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Adenike T Esho, MD",null,"IMS","Participating","Enrollment Complete","2019-08-26",1467745240,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12",13535050,null,"2020-07-21","07/21/2020 - Rec'd spreadsheet from the payer stating this provider is EFF at this service location - Stacey Hudak"]
["Adenike T Esho, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2019-06-12",13535050,null,"2020-07-21","07/21/2020 - Rec'd spreadsheet from the payer stating this provider is EFF at this service location - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-10-01",1467745240,null,"2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Adenike T Esho, MD",null,"Superior","Participating","Enrollment Complete","2019-10-01",1467745240,null,"2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 10-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-08-26",1467745240,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Adenike T Esho, MD",null,"Galaxy Health","Participating","Enrollment Complete","2019-08-26",1467745240,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2015-05-12",1467745240,752656723,"2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Adenike T Esho, MD",null,"USA PPO","Participating","Enrollment Complete","2015-05-12",1467745240,752656723,"2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-08-01",2739018,null,"2020-03-24","3/24/2020-receieved email with roster stating provider PAR 8/1/2019 PID # 2739018\ntisha rader"]
["Adenike T Esho, MD",null,"First Health Coventry","Participating","Enrollment Complete","2019-08-01",2739018,null,"2020-03-24","3/24/2020-receieved email with roster stating provider PAR 8/1/2019 PID # 2739018\ntisha rader"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2015-11-01",1467745240,null,"2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 11-1-2015 under a DIRECT CONTRACT. This service location is linked to the provider. - Stacey Hudak"]
["Adenike T Esho, MD",null,"Aetna","Participating","Enrollment Complete","2015-11-01",1467745240,null,"2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 11-1-2015 under a DIRECT CONTRACT. This service location is linked to the provider. - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-08-14",1467745240,null,"2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 8-14-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Adenike T Esho, MD",null,"Multiplan","Participating","Enrollment Complete","2019-08-14",1467745240,null,"2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 8-14-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2015-03-28",null,null,"2020-12-24","12/24/2020 Confirmed via Self-Service chat provider is currently certified as non-network provider. KFrazier"]
["Adenike T Esho, MD",null,"TriCare Standard","Participating","Enrollment Complete","2015-03-28",null,null,"2020-12-24","12/24/2020 Confirmed via Self-Service chat provider is currently certified as non-network provider. KFrazier"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Adenike T Esho, MD",null,"Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-03",1467745240,null,"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"]
["Adenike T Esho, MD",null,"Scott&White (First Care)","Participating","Enrollment Complete","2019-05-03",1467745240,null,"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"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2014-12-29","383114YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Adenike T Esho, MD",null,"Medicare","Participating","Enrollment Complete","2014-12-29","383114YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-08-14",null,null,"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 8/14/2019.  DCannon"]
["Adenike T Esho, MD",null,"Boon Chapman","Participating","Enrollment Complete","2019-08-14",null,null,"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 8/14/2019.  DCannon"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Adenike T Esho, MD",null,"Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1467745240,null,"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"]
["Adenike T Esho, MD",null,"Humana","Participating","Enrollment Complete","2020-01-01",1467745240,null,"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"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-08-28",1467745240,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 2-20-2020 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Adenike T Esho, MD",null,"Cigna","Participating","Enrollment Complete","2019-08-28",1467745240,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 2-20-2020 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-08-26",1467745240,null,"2020-06-25"]
["Adenike T Esho, MD",null,"Omni PPO","Participating","Enrollment Complete","2019-08-26",1467745240,null,"2020-06-25"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,341837801,79837301,"2020-01-29","01/29/2020 - Found provider PAR through payer portal. Provider is PAR with the following plans: SUPERIOR - FOSTER CARE, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, Superior Health Plan - Lubbock, Superior Health Plan - MRSA West, Amerigroup - MRSA West, Superior HealthPlan - MRSA West, Amerigroup Texas, Inc. - MRSA West, Superior Health Plan - MRSA West - Stacey Hudak"]
["Adenike T Esho, MD",null,"Medicaid","Participating","Enrollment Complete",null,341837801,79837301,"2020-01-29","01/29/2020 - Found provider PAR through payer portal. Provider is PAR with the following plans: SUPERIOR - FOSTER CARE, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, Superior Health Plan - Lubbock, Superior Health Plan - MRSA West, Amerigroup - MRSA West, Superior HealthPlan - MRSA West, Amerigroup Texas, Inc. - MRSA West, Superior Health Plan - MRSA West - Stacey Hudak"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Adenike T Esho, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",13510925,null,"2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Adenike T Esho, MD",null,"CAQH","Participating","CAQH Reattested","2023-06-05",13510925,null,"2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Adenike T Esho, MD","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-04-01",null,null,"2021-11-03","11/3/2021 Per follow-up notes.  NPI# for the provider is on file, shows Linked and Certified , In network  under the group and TIN# at this location,  effective 4/1/2021 -  no termination date, Provider ID is 75-2656723-79706-C006.  DCannon"]
["Adenike T Esho, MD",null,"Tricare Prime","Participating","Enrollment Complete","2021-04-01",null,null,"2021-11-03","11/3/2021 Per follow-up notes.  NPI# for the provider is on file, shows Linked and Certified , In network  under the group and TIN# at this location,  effective 4/1/2021 -  no termination date, Provider ID is 75-2656723-79706-C006.  DCannon"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-07-13",null,null,"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",null,"Boon Chapman","Participating","Enrollment Complete","2016-07-13",null,null,"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","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1770883191,null,"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"]
["Haritha Bellam, MD",null,"Superior","Participating","Enrollment Complete","2017-01-01",1770883191,null,"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"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-13",1770883191,null,"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"]
["Haritha Bellam, MD",null,"Scott&White (First Care)","Participating","Enrollment Complete","2018-04-13",1770883191,null,"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"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2015-10-01",2785559,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2015 PID # --tisha rader"]
["Haritha Bellam, MD",null,"First Health Coventry","Participating","Enrollment Complete","2015-10-01",2785559,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2015 PID # --tisha rader"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2015-10-26",1770883191,752656723,"2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Haritha Bellam, MD",null,"USA PPO","Participating","Enrollment Complete","2015-10-26",1770883191,752656723,"2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2015-10-15",1770883191,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"]
["Haritha Bellam, MD",null,"Caprock (CapStar)","Participating","Enrollment Complete","2015-10-15",1770883191,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"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1770883191,null,"2020-07-17","7/17-2020 - Received email spreadsheet from the payor confirming that his provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Haritha Bellam, MD",null,"Humana","Participating","Enrollment Complete","2020-01-01",1770883191,null,"2020-07-17","7/17-2020 - Received email spreadsheet from the payor confirming that his provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-02-12",1770883191,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 2-12-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Haritha Bellam, MD",null,"Cigna","Participating","Enrollment Complete","2019-02-12",1770883191,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 2-12-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-04-14",null,null,"2020-10-30","10/30/2020 Confirmed provider is certified as non-network with Tax ID and location effective 4/14/2018. Kimberly Frazier"]
["Haritha Bellam, MD",null,"TriCare Standard","Participating","Enrollment Complete","2018-04-14",null,null,"2020-10-30","10/30/2020 Confirmed provider is certified as non-network with Tax ID and location effective 4/14/2018. Kimberly Frazier"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Haritha Bellam, MD",null,"Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-08-10",1770883191,null,"2020-06-05","06/05/2020 - rec'd email from the payer stating provider is EFF - stacey Hudak"]
["Haritha Bellam, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2018-08-10",1770883191,null,"2020-06-05","06/05/2020 - rec'd email from the payer stating provider is EFF - stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Haritha Bellam, MD",null,"Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01",null,null,"2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Haritha Bellam, MD",null,"Wellcare","Participating","Enrollment Complete","2022-09-01",null,null,"2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2015-12-01",1770883191,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Also showing 01/01/2020 and 11/1/16 and 1/1/17 as effective dates.  Tisha Rader"]
["Haritha Bellam, MD",null,"Amerigroup","Participating","Enrollment Complete","2015-12-01",1770883191,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Also showing 01/01/2020 and 11/1/16 and 1/1/17 as effective dates.  Tisha Rader"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2015-10-26",1770883191,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Haritha Bellam, MD",null,"IMS","Participating","Enrollment Complete","2015-10-26",1770883191,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,347934701,79837301,"2020-01-29","01/29/2020 - Found effective info through payer portal. Provider is PAR with the following plans; SUPERIOR - FOSTER CARE, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Superior Health Plan - Lubbock, Superior Health Plan - MRSA West, Amerigroup - MRSA West, Superior HealthPlan - MRSA West, Amerigroup Texas, Inc. - MRSA West, Superior Health Plan - MRSA West - Stacey Hudak"]
["Haritha Bellam, MD",null,"Medicaid","Participating","Enrollment Complete",null,347934701,79837301,"2020-01-29","01/29/2020 - Found effective info through payer portal. Provider is PAR with the following plans; SUPERIOR - FOSTER CARE, Superior HealthPlan - Lubbock, Superior HealthPlan - Lubbock, TRADITIONAL MEDICAID, Amerigroup - MRSA West, Superior Health Plan - Lubbock, Superior Health Plan - MRSA West, Amerigroup - MRSA West, Superior HealthPlan - MRSA West, Amerigroup Texas, Inc. - MRSA West, Superior Health Plan - MRSA West - Stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Haritha Bellam, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2015-11-19",1770883191,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Haritha Bellam, MD",null,"Galaxy Health","Participating","Enrollment Complete","2015-11-19",1770883191,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2018-04-14",null,null,"2020-12-21","12/21/2020 Upon review of the Self-Service portal, provider has been fully re-credentialed as it's listed as 'complete'. KFrazier"]
["Haritha Bellam, MD",null,"Tricare Prime","Participating","Enrollment Complete","2018-04-14",null,null,"2020-12-21","12/21/2020 Upon review of the Self-Service portal, provider has been fully re-credentialed as it's listed as 'complete'. KFrazier"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2015-07-01",1770883191,null,"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",null,"Aetna","Participating","Enrollment Complete","2015-07-01",1770883191,null,"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","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2015-10-26",1770883191,null,"2020-06-25"]
["Haritha Bellam, MD",null,"Omni PPO","Participating","Enrollment Complete","2015-10-26",1770883191,null,"2020-06-25"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2015-05-11","415412YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Haritha Bellam, MD",null,"Medicare","Participating","Enrollment Complete","2015-05-11","415412YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-07-13",1770883191,"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 7-13-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Haritha Bellam, MD",null,"Multiplan","Participating","Enrollment Complete","2016-07-13",1770883191,"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 7-13-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-04-28",12284010,null,"2023-04-28","4/28/2023 CAQH reviewed and re-attested.  DCannon"]
["Haritha Bellam, MD",null,"CAQH","Participating","CAQH Reattested","2023-04-28",12284010,null,"2023-04-28","4/28/2023 CAQH reviewed and re-attested.  DCannon"]
["Haritha Bellam, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01",1770883191,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Haritha Bellam, MD",null,"United Health Care","Participating","Enrollment Complete","2020-01-01",1770883191,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2018-10-03",1437175163,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"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-11-27",1437175163,null,"2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-08-01",1437175163,null,"2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 8-1-2019  **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-07-07",3218941,null,"2021-07-09","7/9/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 7/7/2021 with assigned provider ID 3218941. KFrazier"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2018-11-30",1437175163,null,"2020-02-12","2/12/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/19/2020 - Rec'd email from multiplan/texas true choice stating that this provider is EFF at this service location - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Enrollment Complete","2020-12-01",null,null,"2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,389669801,79837301,"2020-01-29","01/29/2020 - found provider PAR thorugh payer portal. Provider is linked to the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",12235547,null,"2023-06-05","6/5/2023 - CAQH Reattested by Data Services Team - kavello"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2018-10-01",2485553,null,"2020-06-08","06/08/2020 - Rec'd email from the payer stating this provider/service locaiton is EFF - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2018-11-30",1437175163,null,"2020-06-25"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-10-29",1437175163,"52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 10-29-2018. Provider is networked with Beechstreet. - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2019-09-01",3218941,null,"2021-05-26","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"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",959669,null,"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"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2018-10-03",1437175163,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-01-17",null,null,"2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"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-C","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-02-11",1437175163,null,"2020-09-24","09/24/2020 - moved to completed status after reviewing follow up status - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2018-11-30",1437175163,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-09-01",716134,"0008AH","2020-03-10","03/10/2020 - Signed into PECOS and confirmed that this provider is linked to Premier Family Care as an employee EFF 9-1-2018 - Stacey Hudak"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-10-29",null,null,"2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 10/29/2018.  DCannon"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2018-11-01",1104379,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 11/1/2018 PID # 1104379\ntisha rader"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2018-11-20",1437175163,null,"2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 11/20/2018 – Archie Candiasan"]
["Nanette R Paredes, PA-C","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-09-01",1437175163,null,"2020-03-26","3/26/2020--SW Sandra of Aetna @ 800-353-1232. NPI is on file for the provider and is participating effective 9/1/2019 under group and TIN. DIRECT CONTRACT with Aetna. Physical location is on file. Call ref# 5195894813.\ntisha rader"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2021-12-01",null,null,"2021-12-07","12/7/2021 Rcvd email from SuperiorDelegation that November delegation roster has been completed and providers are loaded under appropriate group TIN/locations effective 12/1/2021.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-11-01",null,null,"2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 11/1/2021. DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2008-11-10","8L9009","0008AH","2020-05-26","05/26/2020 - Signed onto Novitas application checker and used tracking# to find that this reval was approved - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2008-11-10","P02124313","CE1588","2021-11-18","11/18/2021 Received RR Medicare PTAN approval letter instantly.  PTAN # P02124313 - effective 11/10/2008.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2021-11-15",null,null,"2022-03-11","3/11/2022 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 11/15/2021.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-09-01",9560591,null,"2021-09-03","9/3/2021 Received an email from pdmcogz@cigna.com confirming provider is participating under group Tax ID effective 9/1/2021 with assigned provider ID number 9560591. KFrazier"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03",null,null,"2022-04-05","4/5/2022 Rcvd email from Joe Rodriguez at Amerigroup confirming provider is PAR and linked to group TIN/location effective 4/3/2020.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2014-02-15",9326179,null,"2021-12-03","12/3/2021 Per f/u note:  S/W Mark of Aetna @ 800-353-1232. advised app sent on 11/15/2021 with Request ID is 00072104. Rep stated, Provider NPI# is on file for the provider and is participating effective 02/15/2014 under the group and TIN#. PIN: 9326179. Physical location is on file. Call ref# 6060911105.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18",13403339,null,"2020-07-21","07/21/2020 - rec'd spreadsheet stating this provider/TIN/service location are EFF with PRIMED - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2015-09-03",1098037,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-11-01",9560591,null,"2022-02-22","2/22/2022 Received email from pdmcogz@cigna.com. Provider is par with location. Eff 11/01/2021.0PID: 9560591. Cbankston"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2015-03-31",1437356730,null,"2021-05-26","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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2015-03-04",1437356730,"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 3-4-2015. Provider is networked with Beechstreet. - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2014-02-05",1437356730,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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-11-01",1437356730,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2021-11-01",null,null,"2021-12-30","12/30/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 11/1/2021.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2008-04-02",190610903,79837301,"2020-03-11","03/11/2020 - Was able to confirm this rpovider is EFF through payer portal/Group TMHP enrollment. The provider is affiliated with the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West  - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-12-01",null,null,"2021-12-14","12/14/2021 Per portal, provider linked to location as of 12/1/2021. Cbankston"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","First Health Coventry","In Process","Enrollment Complete",null,null,null,"2023-01-18","01.18.2023: S/W Teresita of First Health @800-226-5116. Per rep, provider is participating, in network and linked under the group and TIN effective 02/01/2015. Provider ID# 1906310. Physical location is on file. Don't have payer#. Call Ref# 516478. - Mary Rose Acebedo"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-11-01",null,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2008-11-10","8L9009","0008AH","2021-11-18","11/18/2021 Per PECOS provider is PAR and linked to group/location.  PTAN # 8L9009 - effective 11/10/2008.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2021-11-15",null,null,"2021-12-13","12/13/2021 Rcvd Multiplan approval letter.  Provider is PAR effective 11/15/2021.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-12-01",null,null,"2021-12-14","12/14/2021 Provider added to location per portal, as of 12/01/2021. Cbankston"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-14",1437356730,null,"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"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment",null,null,null,"2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2015-03-04",null,null,"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 3/4/2015.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2021-11-01",null,null,"2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 11/1/2021. DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-04-03",null,null,"2021-03-15","3/15/2021 - Per online verification of Amerigroup provider directory provider is participating at location.  Sending email to payor to obtain effective date.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2015-02-01",1906310,null,"2021-01-18","1/18/2021 - Per follow-up notes provider is now on file and participating under group, location and TIN effective 2/1/2015 PID # 1906310.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2015-03-17",null,null,"2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 3/17/2015.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2015-02-16",1437356730,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1437356730,null,"2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",null,null,null,"2022-02-13","2/13/2022 Per Tricare portal, provider is linked to location as of 12.14.2022. Cbankston"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2015-02-16",1437356730,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2021-11-01",null,null,"2021-12-12","12/12/2021 Sent f/u email to Michelle Monroe at Galaxy to check status of November Delegated Roster load.  Per email response November Delegated Roster load has been completed and provider is PAR w/ group/location effective 11/1/2021.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2021-11-15",12669221,null,"2022-02-24","2/24/2022 Per follow-up note from 2/18/2022 -  NPI# for the provider is on file, shows linked and Par under the group and TIN# effective 11/15/2021, the physical location is on file and the Provider ID is 12669221.   DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2008-04-02",1437356730,null,"2022-04-14","4/13/2022 Per TMHP portal provider is PAR and linked to group/location effective 4/2/2008.  Provider ID - 1437356730.  DCannon"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2015-02-16",1437356730,null,"2020-06-25"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-03-01",1437356730,null,"2020-02-03","02/03/2020 - this provider is EFF 1-1-2008 under a DELEGATED AGREEMENT with Primed Health Network. No additional information was provided - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1437356730,null,"2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF with this TIN under PRIMED DELEGATED agreement - Stacey Hudak"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",null,2854139,null,"2022-04-08","4/8/2022 Received email from united_healthcare_provider_operations@uhc.com, provider complete. MPIN 002854139. Cbankston"]
["Johnny L Flitton, PA-C","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",12235261,null,"2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01",1760501720,null,"2020-08-31","08/31/2020 - Moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"United Health Care","Participating","Enrollment Complete","2020-01-01",1760501720,null,"2020-08-31","08/31/2020 - Moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"United Health Care","Participating","Enrollment Complete","2020-01-01",1760501720,null,"2020-08-31","08/31/2020 - Moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-03-10",13752595,null,"2023-03-10","3/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Gerardo M Catalasan, MD",null,"CAQH","Participating","CAQH Reattested","2023-03-10",13752595,null,"2023-03-10","3/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Gerardo M Catalasan, MD",null,"CAQH","Participating","CAQH Reattested","2023-03-10",13752595,null,"2023-03-10","3/10/2023 CAQH reviewed and re-attested.  DCannon"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","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",null,"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",null,"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","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-12-01",null,null,"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",null,"Aetna","Participating","Enrollment Complete","2020-12-01",null,null,"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",null,"Aetna","Participating","Enrollment Complete","2020-12-01",null,null,"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","PE - Premier Family Care, Inc","Liberty Mutual","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD",null,"Liberty Mutual","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD",null,"Liberty Mutual","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-04-03",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gerardo M Catalasan, MD",null,"Boon Chapman","Participating","Enrollment Complete","2020-04-03",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gerardo M Catalasan, MD",null,"Boon Chapman","Participating","Enrollment Complete","2020-04-03",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-03-29",194527101,79837301,"2020-08-13","8/13/2020 - confirmed that this provider is now affiliated with the proper service location through TMHP portal - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Medicaid","Participating","Enrollment Complete","2020-03-29",194527101,79837301,"2020-08-13","8/13/2020 - confirmed that this provider is now affiliated with the proper service location through TMHP portal - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Medicaid","Participating","Enrollment Complete","2020-03-29",194527101,79837301,"2020-08-13","8/13/2020 - confirmed that this provider is now affiliated with the proper service location through TMHP portal - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-04-03",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gerardo M Catalasan, MD",null,"Multiplan","Participating","Enrollment Complete","2020-04-03",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gerardo M Catalasan, MD",null,"Multiplan","Participating","Enrollment Complete","2020-04-03",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2008-05-13",1760501720,null,"2020-06-25"]
["Gerardo M Catalasan, MD",null,"Omni PPO","Participating","Enrollment Complete","2008-05-13",1760501720,null,"2020-06-25"]
["Gerardo M Catalasan, MD",null,"Omni PPO","Participating","Enrollment Complete","2008-05-13",1760501720,null,"2020-06-25"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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",null,"Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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",null,"Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2012-03-01",1760501720,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Additional effective dates on roster are:\n11/1/16,  8/1/12,  1/1/20, and 1/1/17---Tisha Rader"]
["Gerardo M Catalasan, MD",null,"Amerigroup","Participating","Enrollment Complete","2012-03-01",1760501720,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Additional effective dates on roster are:\n11/1/16,  8/1/12,  1/1/20, and 1/1/17---Tisha Rader"]
["Gerardo M Catalasan, MD",null,"Amerigroup","Participating","Enrollment Complete","2012-03-01",1760501720,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Additional effective dates on roster are:\n11/1/16,  8/1/12,  1/1/20, and 1/1/17---Tisha Rader"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-20",1760501720,null,"2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Gerardo M Catalasan, MD",null,"Scott&White (First Care)","Participating","Enrollment Complete","2018-04-20",1760501720,null,"2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Gerardo M Catalasan, MD",null,"Scott&White (First Care)","Participating","Enrollment Complete","2018-04-20",1760501720,null,"2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1760501720,null,"2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1760501720,null,"2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1760501720,null,"2020-06-05","06/05/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Gerardo M Catalasan, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Gerardo M Catalasan, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1760501720,null,"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",null,"Superior","Participating","Enrollment Complete","2017-01-01",1760501720,null,"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",null,"Superior","Participating","Enrollment Complete","2017-01-01",1760501720,null,"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","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2008-09-01",1901802,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2008 PID # 1901802\ntisha rader"]
["Gerardo M Catalasan, MD",null,"First Health Coventry","Participating","Enrollment Complete","2008-09-01",1901802,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2008 PID # 1901802\ntisha rader"]
["Gerardo M Catalasan, MD",null,"First Health Coventry","Participating","Enrollment Complete","2008-09-01",1901802,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2008 PID # 1901802\ntisha rader"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2014-11-08",1760501720,null,"2020-09-21","09/21/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"TriCare Standard","Participating","Enrollment Complete","2014-11-08",1760501720,null,"2020-09-21","09/21/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"TriCare Standard","Participating","Enrollment Complete","2014-11-08",1760501720,null,"2020-09-21","09/21/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2010-09-20",1760501720,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-20-2010 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Cigna","Participating","Enrollment Complete","2010-09-20",1760501720,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-20-2010 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Cigna","Participating","Enrollment Complete","2010-09-20",1760501720,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-20-2010 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Gerardo M Catalasan, MD",null,"Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Gerardo M Catalasan, MD",null,"Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gerardo M Catalasan, MD",null,"Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gerardo M Catalasan, MD",null,"Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2008-05-13",1760501720,null,"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",null,"IMS","Participating","Enrollment Complete","2008-05-13",1760501720,null,"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",null,"IMS","Participating","Enrollment Complete","2008-05-13",1760501720,null,"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","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2014-05-12",1760501720,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Galaxy Health","Participating","Enrollment Complete","2014-05-12",1760501720,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gerardo M Catalasan, MD",null,"Galaxy Health","Participating","Enrollment Complete","2014-05-12",1760501720,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gerardo M Catalasan, MD","PE - 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",null,"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",null,"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","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD",null,"USA PPO","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD",null,"USA PPO","Participating","Enrollment Complete","2009-10-23",1760501720,752656723,"2020-08-26","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Gerardo M Catalasan, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Gerardo M Catalasan, MD",null,"Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Gerardo M Catalasan, MD",null,"Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-05-13",8867748,null,"2020-05-14","05/14/2020 - Rec'd email from the payer stating \"Congratulations! Your application to participate in the Cigna network has been approved. Your effective date is 05/13/2020. Your provider identification number is 8867748. \" - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"Cigna","Participating","Enrollment Complete","2020-05-13",8867748,null,"2020-05-14","05/14/2020 - Rec'd email from the payer stating \"Congratulations! Your application to participate in the Cigna network has been approved. Your effective date is 05/13/2020. Your provider identification number is 8867748. \" - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2014-11-28",1376723361,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader"]
["Jeffrey Limbacher, PA-C",null,"Amerigroup","Participating","Enrollment Complete","2014-11-28",1376723361,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-09-16","1K2721","0008AH","2020-12-17","12/17/2020 Received email of approval with assigned PTAN 1K2721, effective 9/16/2020. KFrazier"]
["Jeffrey Limbacher, PA-C",null,"Medicare","Participating","Enrollment Complete","2020-09-16","1K2721","0008AH","2020-12-17","12/17/2020 Received email of approval with assigned PTAN 1K2721, effective 9/16/2020. KFrazier"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1376723361,null,"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",null,"Humana","Participating","Enrollment Complete","2020-01-01",1376723361,null,"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","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Jeffrey Limbacher, PA-C",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1376723361,null,"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",null,"Superior","Participating","Enrollment Complete","2017-01-01",1376723361,null,"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","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-03-01",1376723361,null,"2020-02-03","02/03/2020 - Confirmed that this provider is enrolled with a DIRECT CONTRACT EFF 3-1-2019 - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"Aetna","Participating","Enrollment Complete","2019-03-01",1376723361,null,"2020-02-03","02/03/2020 - Confirmed that this provider is enrolled with a DIRECT CONTRACT EFF 3-1-2019 - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11",1376723361,null,"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",null,"Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11",1376723361,null,"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","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30",1376723361,null,"2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal.  - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"TriCare Standard","Participating","Enrollment Complete","2018-11-30",1376723361,null,"2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal.  - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",13780299,null,"2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Jeffrey Limbacher, PA-C",null,"CAQH","Participating","CAQH Reattested","2023-06-05",13780299,null,"2023-06-05","6/5/2023- CAQH Reattested by Data Services - kavello"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Jeffrey Limbacher, PA-C",null,"Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-01-03",null,null,"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",null,"Multiplan","Participating","Enrollment Complete","2022-01-03",null,null,"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","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2014-12-01",1376723361,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"]
["Jeffrey Limbacher, PA-C",null,"Caprock (CapStar)","Participating","Enrollment Complete","2014-12-01",1376723361,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"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01",1376723361,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"United Health Care","Participating","Enrollment Complete","2020-01-01",1376723361,null,"2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2017-02-01",190978001,79837301,"2021-02-08","2/8/2021 - Per f/u notes provider is participating at location  and under TIN effective 2/1/2017 TIP # 190978001.  DCannon"]
["Jeffrey Limbacher, PA-C",null,"Medicaid","Participating","Enrollment Complete","2017-02-01",190978001,79837301,"2021-02-08","2/8/2021 - Per f/u notes provider is participating at location  and under TIN effective 2/1/2017 TIP # 190978001.  DCannon"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2014-11-28",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jeffrey Limbacher, PA-C",null,"USA PPO","Participating","Enrollment Complete","2014-11-28",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeffrey Limbacher, PA-C",null,"Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"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",null,"Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"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","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-07-25",13512484,null,"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",null,"HealthSmart PPO","Participating","Enrollment Complete","2016-07-25",13512484,null,"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","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2017-11-28",1376723361,null,"2020-06-25"]
["Jeffrey Limbacher, PA-C",null,"Omni PPO","Participating","Enrollment Complete","2017-11-28",1376723361,null,"2020-06-25"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-01-03",null,null,null,"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",null,"Boon Chapman","Participating","Enrollment Complete","2022-01-03",null,null,null,"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","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2017-11-28",1376723361,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"IMS","Participating","Enrollment Complete","2017-11-28",1376723361,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Jeffrey Limbacher, PA-C","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2016-05-18",1376723361,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",null,"Galaxy Health","Participating","Enrollment Complete","2016-05-18",1376723361,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/1/2020.   DCannon"]
["Adriana E Nur, MD",null,"Boon Chapman","Participating","Enrollment Complete","2020-05-01",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/1/2020.   DCannon"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-01-01",8553905,null,"2020-02-27","02/27/2020 - Rec'd email response from the payer stating that this provider is EFF 1-1-2019 with Premier Family under PID# 8553905 - Stacey Hudak"]
["Adriana E Nur, MD",null,"Cigna","Participating","Enrollment Complete","2019-01-01",8553905,null,"2020-02-27","02/27/2020 - Rec'd email response from the payer stating that this provider is EFF 1-1-2019 with Premier Family under PID# 8553905 - Stacey Hudak"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2017-11-29",1619982584,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader"]
["Adriana E Nur, MD",null,"Amerigroup","Participating","Enrollment Complete","2017-11-29",1619982584,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-08-09",1877169102,79837301,"2020-11-23","11/23/2020 Received email confirmation revalidation is complete for provider and confirmed next revalidation date for this TPI is 8/9/2025. Kimberly Frazier"]
["Adriana E Nur, MD",null,"Medicaid","Participating","Enrollment Complete","2020-08-09",1877169102,79837301,"2020-11-23","11/23/2020 Received email confirmation revalidation is complete for provider and confirmed next revalidation date for this TPI is 8/9/2025. Kimberly Frazier"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Adriana E Nur, MD",null,"Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2017-11-29",1619982584,null,"2020-06-25"]
["Adriana E Nur, MD",null,"Omni PPO","Participating","Enrollment Complete","2017-11-29",1619982584,null,"2020-06-25"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-03-13",10740365,null,"2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Adriana E Nur, MD",null,"CAQH","Participating","CAQH Reattested","2023-03-13",10740365,null,"2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01",1619982584,null,"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"]
["Adriana E Nur, MD",null,"Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01",1619982584,null,"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"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2017-11-29",1619982584,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"]
["Adriana E Nur, MD",null,"Caprock (CapStar)","Participating","Enrollment Complete","2017-11-29",1619982584,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"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Adriana E Nur, MD",null,"Humana","Participating","Enrollment Complete","2020-01-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2020-05-01",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/1/2020.   DCannon"]
["Adriana E Nur, MD",null,"Multiplan","Participating","Enrollment Complete","2020-05-01",null,null,"2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/1/2020.   DCannon"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2017-10-31",3110523,null,"2020-07-28","7-28-2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Adriana E Nur, MD",null,"United Health Care","Participating","Enrollment Complete","2017-10-31",3110523,null,"2020-07-28","7-28-2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2017-11-29",1619982584,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Adriana E Nur, MD",null,"IMS","Participating","Enrollment Complete","2017-11-29",1619982584,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2017-11-29",1619982584,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Adriana E Nur, MD",null,"Galaxy Health","Participating","Enrollment Complete","2017-11-29",1619982584,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30",1619982584,null,"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"]
["Adriana E Nur, MD",null,"TriCare Standard","Participating","Enrollment Complete","2018-11-30",1619982584,null,"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"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2017-08-01","P02450595","CE1588","2020-06-11","06/11/2020 - found EFF info through payer portal - Stacey Hudak"]
["Adriana E Nur, MD",null,"Rail Road Medicare","Participating","Enrollment Complete","2017-08-01","P02450595","CE1588","2020-06-11","06/11/2020 - found EFF info through payer portal - Stacey Hudak"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26",1082395,null,"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"]
["Adriana E Nur, MD",null,"USA PPO","Participating","Enrollment Complete","2021-01-26",1082395,null,"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"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Adriana E Nur, MD",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2017-08-01","365428YPVD","0008AH","2020-01-29","01/29/2020 - FOR PREMIER FAMILY confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Adriana E Nur, MD",null,"Medicare","Participating","Enrollment Complete","2017-08-01","365428YPVD","0008AH","2020-01-29","01/29/2020 - FOR PREMIER FAMILY confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1619982584,null,"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"]
["Adriana E Nur, MD",null,"Superior","Participating","Enrollment Complete","2020-08-01",1619982584,null,"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"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-03-27",null,null,"2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 3/27/2019.  DCannon"]
["Adriana E Nur, MD",null,"HealthSmart PPO","Participating","Enrollment Complete","2019-03-27",null,null,"2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 3/27/2019.  DCannon"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-03-01",1619982584,null,"2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 3-1-2019 under a DIRECT CONTRACT. This service location is on file - Stacey Hudak"]
["Adriana E Nur, MD",null,"Aetna","Participating","Enrollment Complete","2019-03-01",1619982584,null,"2020-02-03","02/03/2020 - Rec'd confirmation from the payer that this provider is EFF 3-1-2019 under a DIRECT CONTRACT. This service location is on file - Stacey Hudak"]
["Adriana E Nur, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2017-12-01",1950288,null,"2020-03-20","03/20/2020 - Rec'd email with roster from payor stating provider PAR 12/1/2017 PID # 1950288-tisha rader"]
["Adriana E Nur, MD",null,"First Health Coventry","Participating","Enrollment Complete","2017-12-01",1950288,null,"2020-03-20","03/20/2020 - Rec'd email with roster from payor stating provider PAR 12/1/2017 PID # 1950288-tisha rader"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-06-01",1558392779,"52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 6-13-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-04",1558392779,null,"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","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2013-09-28",1558392779,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-06-29",1558392779,null,"2020-07-09","07/09/2020 - Rec'd welcome letter stating this provider is EFF with amerigroup STAR, STAR PLUS, Star Kids products through Texas True Choice - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2010-04-16",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-04-19",12024587,null,"2023-04-19","4/19/2023 CAQH reviewed and re-attested.  DCannon"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30",1558392779,null,"2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2011-06-01",1958740,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 6/1/2011 PID # 1958740\ntisha rader"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2012-01-01",1558392779,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"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1558392779,null,"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"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,187586602,79837301,"2021-03-25","3/25/2021 Per TMHP Provider Portal provider revalidation has been completed.  Revalidation date 2/25/2026.  DCannon"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2010-02-26",1558392779,null,"2020-08-13","IMS Complete"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2010-08-01",1558392779,null,"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"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01",1558392779,null,"2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-06-01",null,null,"2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 6/1/2016.  DCannon"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2010-01-04","8L22951","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2010-06-06",3015766,null,"2020-06-08","06/08/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1558392779,null,"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"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2010-02-26",1558392779,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Juan C Gil, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2012-02-23",1558392779,null,"2020-03-26","3/26/2020--SW Jona of Aetna @ 800-353-1232. NPI is on file for the provider 2/23/2012 under group and TIN. Directly contracted with Aetna. Directly contracted with Aetna. Physcal location is on file. Call ref# 5196144885.\ntisha rader"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2006-06-01",1487837712,"West Texas Physicians Alliance","2020-09-28","09/28/2020 - Rec'd spreadsheet from the payer stating this provider is EFF under that West Texas Physicians Alliance delegation. This provider is networked with: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2012-03-01",1487837712,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- dditional effective dates listed on roster are:\n11/1/16,  8/1/12,  1/1/20,  and 1/1/17---Tisha Rader"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-13",1487837712,null,"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"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2010-02-26",1487837712,null,"2020-06-25"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-06-05",12038216,null,"2023-06-05","6/5/2023 - CAQH Reattested by Data Services - kavello"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-01-01",1487837712,null,"2020-08-03","8/3/2020 - Emailed Tracy Diapolo and confirmed this provider is NOT with PriMed. That agreement has dissoled with UHC and the phone rep was incorrect in sharing this information. However, she confirmed the provider has been credentialed directly with UHC and all else is well. - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2010-02-26",1487837712,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2010-04-15",null,null,"2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 4-15-2010 under a DIRECT CONTRACT. Next recred is 1-26-2021 and this service location is linked to the provider - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01",1487837712,null,"2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2012-02-23",1487837712,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1487837712,null,"2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2012-07-01",1487837712,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 7-1-2012 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-02-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 2/1/2022.  DCannon"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2018-11-30",1487837712,null,"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"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2010-01-01","8L23968","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2020-04-01",2122957,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 4/1/2020 PID # 2122957\ntisha rader"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2006-06-01",null,null,"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 6/1/2006.  DCannon"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2010-06-25",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18",1487837712,null,"2020-06-10","06/10/2020 - Rec'd a spreadsheet from the payer stating this provider is EFF - Stacey Hudak"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Rosanna Y Catalasan, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,209024301,79837301,"2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2016-10-26",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,352749103,79837301,"2020-01-29","01/29/2020 - Found provider par through payer portal. Provider is active with the following plans: TRADITIONAL MEDICAID, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2016-07-08",1437402278,null,"2020-06-25"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2016-07-08",1437402278,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2016-07-01",2876013,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 7/1/2016 PID # 2876013"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2016-03-21","299111YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-11",1437402278,null,"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"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2016-07-08",1437402278,null,"2020-02-12","2/12/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/20/2020 - Rec'd email from Multiplan/Texas True Choice confirming that this Amerigroup EFF info is true for this provider/service location - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-07-08",1437402278,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"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2015-12-15",4689558,null,"2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 12-15-2015 under a DIRECT CONTRACT. Midlevels dont require recred. This service location is linked to the provider profile - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2016-08-01",1437402278,null,"2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 8-1-2016 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-04-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-01-27",null,null,"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 1/27/2016.  DCannon"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1437402278,null,"2020-07-17","7/17/2020 - Received email spreadsheet from the payor confirming that this provider is EFF atthis service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-05-07",null,null,"2021-07-09","7/2/2021- S/W Joel OF TRICARE Standard @ 8004445445, call was transferred to WPS for further assistance, Spoke to Stacy, as per Rep, NPI#is on file for the provider, shows link and Par under the group and TIN# effective 5/7/2019 w/ no term date under this location. Provider ID is 75-2656723-79701-P015. Call ref#13096127.- Herminia Gilongos"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-06-01",1437402278,null,"2020-02-20","02/20/2020 - Rec'd confirmation from the payer that this provider is EFF as of 6-1-2019 and linked to this locaiton - However, the provider is affiliated with a DELEGATED group. Cigna could not identify the delegated entity - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2016-05-07",null,null,"2020-12-01","12/1/2020 - Per f/u report Provider is on file and Par under the group and TIN# effective 5/7/2016.  DCannon"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2016-07-08",1437402278,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-01-27",1437402278,"Permian Basin Healthcare Network","2020-09-28","09/28/2020 - Rec'd spreadsheet from the payer stating this provider is EFF through: Permian Basin Healthcare Network with the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-03-13",12567903,null,"2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2018-09-25",1437402278,null,"2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-03-20",1437402278,null,"2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hduak"]
["Matthew A Sanchez, APRN-NP","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-10-05",1619008141,null,"2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1619008141,null,"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"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-10-12",1619008141,"52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 10-12-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2016-10-05",1619008141,null,"2020-02-12","2/12/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n03/20/2020 - Rec'd confirmation from Multiplan/Texas True Choice is EFF for this provider/service location. - stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2016-10-05",1619008141,null,"2020-06-25"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2016-07-20",1619008141,null,"2021-05-25","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"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2016-10-05",1619008141,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2016-10-05",1619008141,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2016-10-26",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-10-05",1619008141,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"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",9223693,null,"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 9223693. KFrazier"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2016-09-24",1619008141,null,"2020-09-09","09/09/2020 - moved to completed status after reviewing last note - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01",null,null,"2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-05-10",1619008141,null,"2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 5-10-2019 under a DIRECT CONTRACT. This service location is on file and recred will be \" On or before 05/10/2022 (reval/recred every 3 years)\" - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-10-12",null,null,"2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 10/12/2016.  DCannon"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2016-08-01","518857YPVD","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-01-01",1619008141,null,"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"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2017-01-09",2907601,null,"2020-06-08","06/08/2020 - Rec'd email from the payer statign provider is EFF at this service location as of 01/09/2017 - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-04",11857339,null,"2023-05-04","5/4/2023 CAQH reviewed and re-attested.  DCannon"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1619008141,null,"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"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,361391101,79837301,"2020-08-13","8/13/2020 - signed into TMHP to find that the next recred date has been pushed out to 2025. Recred approved - Stacey Hudak"]
["Joan S R Petalcorin, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2016-10-01",1903184,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 10/1/2016 PID # 1903184\ntisha rader"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-01",null,null,"2020-09-21","Confirmed via self-service portal provider is participating under group at this location as of 5/1/2020. Kimberly Frazier"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2019-01-01",1053601344,null,"2021-05-26","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"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2019-04-01",null,null,"2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 4/1/2019.  DCannon"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-02-01",1053601344,null,"2020-10-02","10/02/2020- moved to the completed status after reviewing follow up note - Stacey Hudak"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-05-21",1053601344,null,"2020-04-23","04/23/2020--S/W Christine 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 #5535943. Call ref # 5234061830\ncopied note from spreadsheet-tisha rader"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01",1053601344,null,"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"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21",1053601344,null,"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","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,365597905,79837301,"2020-01-29","01/29/2020 - Found provider through payer portal. Provider is linked to the following plans: Texas Children's Health Plan - Harris, Texas Children's Health Plan - Jefferson, TRADITIONAL MEDICAID, Texas Children's Health Plan - Harris, Texas Children's Health Plan - Jefferson, Texas Children's Health Plan - MRSA Northeast, Amerigroup - MRSA West, Amerigroup Texas, Inc. - MRSA West - Stacey Hudak"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"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"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-05-21",1053601344,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-03-03",1053601344,null,"2020-09-24","Delegated Entity Name: UT PHYSICIANS (PREV. UCP)\n\n*Primed Delegation termed with UHC on 1/1/2020"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-07-06",6423215,null,"2021-07-07","7/7/2021 Received an email from discovercigna@information.cigna.com confirming provider is participating under group Tax ID effective 7/6/2021 with assigned provider number 6423215. KFrazier"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31",1053601344,null,"2020-06-10","06/10/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21",1053601344,null,"2020-06-26"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-04-04",1053601344,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"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31",null,null,"2020-09-09","Confirmed provider is participating with PPO, H&W and GEN networks (GEN is behavioral health) (list of networks attached). Kimberly Frazier"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-04",null,null,"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"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-04",1053601344,"52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 4-4-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Tiffany D Cossey, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31",1053601344,null,"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"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-08-01",1659728855,null,"2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 8-1-2019 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-08-07",1659728855,"52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 8-7-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-06-12",13681723,null,"2020-07-21","07/21/2020 - rec'd spreadsheet from the payer stating this provider is EFF with this TIN/service location as of 6-12-2019 under the WEST TEXAS PHYSICIANS ALLIANCE MDDO delegation - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01",null,null,"2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-06-14",1659728855,null,"2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-10-04",1659728855,null,"2020-02-03","02/03/2020 - Confirmed with the payer that this provider is EFF 10-4-2019 under a DIRECT CONTRACT. Next recred is 10-4-2022 and service location is on file and linked to provider - Stacey  Hudak"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01",null,null,"2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Casey Mraz, MD","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-06-16",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,396567501,79837301,"2020-01-29","01/29/2020 - Provider is linked to group. Provider is only PAR with traditional medicaid - stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-10-21",1659728855,null,"2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/19/2020 - rec'd email from the payer (Multiplan/Texas True Choice) confirming that this EFF info is true - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-05-29",7093824,null,"2020-07-30"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-08-07",null,null,"2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 8/7/2019.  DCannon"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Casey Mraz, MD","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-03-13",14428752,null,"2023-03-13","3/13/2023 CAQH reviewed and re-attested.  DCannon"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-06-01",3278559,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR  6/1/2019 PID # 3278559\ntisha rader"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-05-31",1659728855,null,"2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01",1659728855,null,"2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-06-12",1659728855,null,"2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-06-14",1659728855,null,"2020-06-25"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12",1659728855,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"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-04-01",786679,"0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2021-01-08",null,null,"2021-03-31","3/31/2021 Confirmed provider certified at location via Humana-Military portal effective 1/8/2021.  DCannon"]
["Casey Mraz, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-09-20",1659728855,null,"2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 9-20-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Saranya Rajasekar, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"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",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"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",null,"Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"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","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Boon Chapman","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"IMS","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"IMS","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"HealthSmart PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2023-05-04",null,null,"2023-05-04","5/4/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",null,"CAQH","Participating","CAQH Reattested","2023-05-04",null,null,"2023-05-04","5/4/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD",null,"CAQH","Participating","CAQH Reattested","2023-05-04",null,null,"2023-05-04","5/4/2023 CAQH reviewed and re-attested.  DCannon"]
["Saranya Rajasekar, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-06-01",1871028365,1275522864,"2022-08-17","8/17/2022 Rcvd TX Medicaid approval letter.  TPI # 1871028365 - effective 6/1/2022 - 8/15/2027.  DCannon"]
["Saranya Rajasekar, MD",null,"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",null,"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","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-07-01",7352247,null,"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",null,"Cigna","Participating","Enrollment Complete","2022-07-01",7352247,null,"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",null,"Cigna","Participating","Enrollment Complete","2022-07-01",7352247,null,"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","PE - Premier Family Care, Inc","First Health Coventry","In Process","Enrollment Complete",null,null,null,"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",null,"First Health Coventry","In Process","Enrollment Complete",null,null,null,"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",null,"First Health Coventry","In Process","Enrollment Complete",null,null,null,"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","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"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",null,"Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"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",null,"Wellcare","Participating","Enrollment Complete","2022-05-01",null,null,"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","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-04-11",8166209,null,"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",null,"United Health Care","Participating","Enrollment Complete","2022-04-11",8166209,null,"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",null,"United Health Care","Participating","Enrollment Complete","2022-04-11",8166209,null,"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","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Amerigroup","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Amerigroup","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-11-20",null,null,"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",null,"Wellmed","Participating","Enrollment Complete","2022-11-20",null,null,"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",null,"Wellmed","Participating","Enrollment Complete","2022-11-20",null,null,"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","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Humana","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"USA PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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",null,"Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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",null,"Ambetter","Participating","Enrollment Complete","2022-05-01",null,null,"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","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Multiplan","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-06-01","Q00267344","CE1588","2022-05-26","5/26/2022 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00267344 - effective 6/1/2022.  DCannon"]
["Saranya Rajasekar, MD",null,"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",null,"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","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Caprock (CapStar)","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-01",6655255,null,"2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",null,"Aetna","Participating","Enrollment Complete","2022-11-01",6655255,null,"2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",null,"Aetna","Participating","Enrollment Complete","2022-11-01",6655255,null,"2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Galaxy Health","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-05-01",null,null,"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",null,"Superior","Participating","Enrollment Complete","2022-05-01",null,null,"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",null,"Superior","Participating","Enrollment Complete","2022-05-01",null,null,"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","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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",null,"Omni PPO","Participating","Enrollment Complete","2022-04-11",null,null,"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","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10",null,null,"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",null,"Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10",null,null,"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",null,"Scott&White (First Care)","Participating","Enrollment Complete","2022-05-10",null,null,"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","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-06-01","2D4132","0008AH","2022-05-18","5/18/2022 Per PECOS provider is PAR and linked to group/location effective 6/1/2022.  PTAN # 2D4132.  DCannon"]
["Saranya Rajasekar, MD",null,"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",null,"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"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2019-01-01",1396930426,null,"2021-05-26","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"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21",1396930426,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"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"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","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-05",1396930426,"West Texas Physicians Alliance","2020-09-28","09/28/2020 - moved to completed status after receiving a spreadsheet from the payer stating this provider is EFF with West Texas Physicians Alliance under the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-01-01",3382000,null,"2020-06-08","06/8/2020 - Rec'd email from the payer stating this provider/address is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-01-07",761311,"0008AH","2020-04-27","04/27/2020 - Confirmed enrollment through GROUP PECOS enrollment - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",669817,null,"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","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-05",null,null,"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","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21",1396930426,null,"2020-06-26"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21",1396930426,null,"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","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-05-21",1396930426,null,"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","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-01-31",1396930426,null,"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","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-01",null,null,"2021-04-02","4/2/2021 Per Humana Military Portal provider is certified and linked to group TIN and location effective 5/1/2020.  DCannon"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01",2323463,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31",1396930426,null,"2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"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","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31",1396930426,null,"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","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,283737907,79837301,"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","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-05-01",null,null,"2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-11-01",null,null,"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","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2019-04-04",1396930426,null,"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","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01",2323463,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]

{"sheet":"NPISearch","index":3,"n_rows":24,"n_cols":11,"rows_kept":24,"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"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Cigna","Terminated","Terminated","2019-01-01",1396930426,null,"2021-05-26","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"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-05-21",1396930426,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"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment",null,null,null,"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","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2019-04-05",1396930426,"West Texas Physicians Alliance","2020-09-28","09/28/2020 - moved to completed status after receiving a spreadsheet from the payer stating this provider is EFF with West Texas Physicians Alliance under the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-01-01",3382000,null,"2020-06-08","06/8/2020 - Rec'd email from the payer stating this provider/address is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-01-07",761311,"0008AH","2020-04-27","04/27/2020 - Confirmed enrollment through GROUP PECOS enrollment - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-31",669817,null,"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","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-04-05",null,null,"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","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21",1396930426,null,"2020-06-26"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21",1396930426,null,"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","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-05-21",1396930426,null,"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","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-01-31",1396930426,null,"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","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-05-01",null,null,"2021-04-02","4/2/2021 Per Humana Military Portal provider is certified and linked to group TIN and location effective 5/1/2020.  DCannon"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01",2323463,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31",1396930426,null,"2020-06-10","06/10/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01",null,null,"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","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-05-31",1396930426,null,"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","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2019-05-31",null,null,"2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",null,283737907,79837301,"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","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-05-01",null,null,"2020-10-08","10/8/2020 Confirmed via Self-Service Portal provider is participating under Tax ID and location. Kimberly Frazier"]
["Tzu-Ching Wu, MD","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-11-01",null,null,"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","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2019-04-04",1396930426,null,"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","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2019-05-01",2323463,null,"2020-03-20","3/20/2020-receieved email with roster stating provider PAR 5/1/2019 PID # 2323463\ntisha rader"]