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["Providers Full Name","Providers NPI","Tax ID#","State","Practice Name","Payor Name","Enrollment Status","Current Status","Effective Date","Indv ID#","Grp ID#","Note Date","Notes","Symplr Rep","Enroll Type","Practice Address","Practice Address 2","Practice City","Practice Zip Code"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-10-17","","","2023-10-27","Ste. 102 and 103 effective 10/17/2023 has been approved. MD"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2023-10-17","","","2023-10-27","Ste. 102 and 103 effective 10/17/2023 has been approved. MD"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Stopped","2023-10-17","","","2023-11-06","Ste. 240, 205, and 107 have been confirmed as non current service addresses. Provider should only be linked to Ste. 103. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Stopped","2023-10-17","","","2023-11-06","Ste. 240, 205, and 107 have been confirmed as non current service addresses. Provider should only be linked to Ste. 103. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2018-08-29","","","2023-11-22","11/22/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/29/2018.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-07-19","","","2023-11-07","11/7/2023 Per email received from Galaxy October delegated roster has been processed and provider is PAR and linked to group/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-07-19","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-07-19","6670877","","2023-11-08","Received confirmation of update. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-07-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-19","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-07-19","5117734","","2023-11-19","11.29.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 07/19/2023. Next recredentialing date is on 07/19/2026. PIN: 5117734. Servicing location is on file. Payer# 60054. Call ref# 6172179371. - Willie Ravas"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-10-17","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-10-01","679507","0008AH","2024-02-07","Location was added to group record eff 10/1/2023. MS"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-11-03","11/3/2023 Rcvd confirmation email from UHC/Wellmed that provider is PAR and linked to group TIN/location effective 1/1/2022.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-07-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",45126,"","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-07-19","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 7/19/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-10-13",""]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-07-19","1046218","","2023-12-06","12/6/2023 S/W Kim of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, Provider is in network with First Health and linked to the group and TIN# effective 7/19/2023.  PIN: 1046218. Servicing location is on file. No payer# available. DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-02-22","","","2024-03-20","Welcome ltr rcvd. Provider effective at this location 02/22/2023. Jen Videan"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45436,"11483093","","2024-05-24","05/24/2024 ALl locations current and all expirables up to date wthompson"]
["Douglas J Colson, MD",1790767119,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2018-07-10","002539407","","2023-11-03","11/3/2023 Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 7/10/2018.  MPIN # 002539407.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","","","2020-09-11",""]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-06-20","","","2021-03-24","3/24/2021 Confirmed provider is already certified as a non-network provider. KFrazier"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing the follow up complete note - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2013-12-27","1023520830","463131679","2020-08-18","Confirmed provider is participating under delegated agreement for PPO and H&W Networks (list of networks attached). Kim Frazier"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-03-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 3/1/2022.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2018-05-02","1023520830","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1023520830","","2020-08-27","08/27/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-11-10","","","2021-09-14","9/14/2021 Per Tricare portal, provider is participating with TaxID as of 11/10/2020. Cbankston"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-03-19","626806YPVD","0008AH","2020-07-21","07/21/20220 - Rec'd email confirmation that this name change has been completed. Signed into PECOS to verify - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1023520830","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2018-03-19","382485601","079837301","2023-05-10","5/10/2023 Rcvd TX Medicaid revalidation approval letter.  Provider is PAR and linked to group.  TPI # 1023520830 - effective 3/19/2018.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-05-30","1023520830","","2020-06-05","06/05/2020 - Rec'd email from payer stating this provider is EFF - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2018-06-15","1023520830","52669: West Texas Physicians Alliance Group Cntrct","2020-03-11","03/11/2020 - Rec'd email response from the payer stating provider is effective with different networks/effective dates as follows:\n\"Network:  MPI \nNetwork Participation effective: 10/01/2019 Group contract through: West Texas Physicians Alliance\n\nNetwork:  PHCS\nNetwork Participation effective: 06/15/2018 Group contract through: West Texas Physicians Alliance\n\nNetwork:  Beech St.\nNetwork Participation effective: 11/27/2019 Group contract through: West Texas Physicians Alliance\"\n\nAll are linked to group TIN - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-06-15","1023520830","","2020-10-05","Enrolled thru PHCS"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-07-11","1023520830","","2020-02-19","2/19/2020--Per payer roster received from Irma Henson, this provider is participating with this service location and TIN--tisha rader"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-05-24","14145595","","2024-05-24","05/24/2024 CAQH Reattested All locations current and all expirables up to date wthompson"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-06-29","1023520830","","2020-07-09","07/09/2020 - Rec'd welcome letter from Multiplan stating provider is covered for all governmental payers - Amerigroup is covered (STAR, Star Plus, Star Kids) - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-05-19","12623755","","2021-08-05","7/26/2021 Received an email from PDMCOGZ@cigna.com with confirmation provider is now participating under group Tax ID effective 5/19/2020 with assigned provider number 12623755. KFrazier"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1023520830","","2020-07-27","IMS is complete"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2018-05-01","3128029","","2020-03-24","3/24/2020-received email with roster from payor stating provider is PAR 5/1/2018 PID # 3128029\ntisha rader"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-09-01","1023520830","","2020-09-02","09/02/2020 - Rec'd email from the payer stating this providers name update from Brown to Reeves has been completed EFF 9-1-2020 - Stacey Hudak"]
["Lori Ann Reeves, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["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","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","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","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","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1104237015","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-16","1104237015","","2020-04-16","04/16/2020 - Rec'd confirmation from the payer stating this provider is EFF under the DELEGATED PRIMED agreement with HMO/PPO only products with this TIN/Service Location- Stacey Hudak\n\n**Verified that this provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nPPO Limited Benefit Network"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2018-06-19","","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of  6/19/2018. – Elonah Grace B. Gelig"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-07-11","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating effective 7/11/2018 with the correct practice location. Kimberly Frazier"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","CAQH","Participating","CAQH Reattested","2024-05-24","14218808","","2024-05-24","05/24/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["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","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","Cigna","Participating","Enrollment Complete","2018-10-11","1104237015","","2020-04-15","04/15/2020 - Rec'd follow up team statement saying \"S/W Francis of Cigna@ 8008824462, provider NPI is on file for the provider and participating effective 10/11/18 under the group and TIN with Direct contract. Physical location is on file. Call ref# FRANCIS04142020. \"  PROVIDER IS PART OF A DIRECT CONTRACT - Stacey Hudak"]
["Coby R Robins, MD",1104237015,"75-2133441","TX","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","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"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","BCBSTX","Participating","Enrollment Complete",45391,"","","2024-04-08","Received email provider is now PAR and participating with the following networks, eff. 4/9/2024:\nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nMCH - Medicare Advantage HMO\nSNP - Dual Eligible Special Needs Plan\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO\nWEL - WellMed MA HMO. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","TriCare Standard","No Enrollment Required","No Enrollment Required","","","","2024-04-01","Enrollment is set up as an ambulatory enrollment and providers can not be added to it. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 10/09/2023 and linked to 400 Rosalind Redfern, Suite 230. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","USA PPO","In Process","Application Submitted","","","","2024-03-19","Submitted application via delegated monthly roster on 03/15/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Par through Multiplan enrollment, eff. 11/06/2023. PA"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email rcvd from Karen Avalos at Galaxy December roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45236,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Rail Road Medicare","No Enrollment Required","No Enrollment Required","","","","2024-04-25","Due to the type of Medicare enrollment, this enrollment is not required. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",45311,"","","2024-01-09","Received confirmation via self service portal. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Wellmed","In Process","Application Submitted","","","","2024-03-22","Submitted application via delegated monthly roster on 03/15/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Wellcare","Participating","Enrollment Complete",45383,"","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Medicare","No Enrollment Required","No Enrollment Required","","","","2024-04-08","Enrollment not required as the type of enrollment is unable to have providers reassigned. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","IMS","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (hpdelegation@bswhealth.org) requesting update on enrollment status. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-24","Pending Aetna approval. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Multiplan","Provider Load","Application Submitted","","","","2024-04-24","4/24/2024 Delegated roster submitted on 4/15/2024. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Ambetter","Participating","Enrollment Complete",45383,"","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete",45293,"","","2024-02-28","Re-Cred has been completed eff 1/2/2024. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Omni PPO","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete",45328,"","","2024-04-16","Received email from Karen Avalos confirming roster completed; provider is PAR under TIN: 75-6000608, eff. 2/06/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45236,"","","2024-02-15","Per phone call, the provider is linked to TIN eff 11/6/2023. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-05-24","","","2024-05-24","05/24/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Cigna","In Process","Pending Contracting","","","","2024-05-07","Resent application directly to the provider to sign. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",45231,"","","2023-12-19","Rcvd TMHP Welcome letter. Provider effective 11/01/2023. Jen Videan"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","HealthSmart PPO","In Process","Application Submitted","","","","2024-03-15","3/15/2024 Submitted provider via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",45236,"","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Cigna Healthspring","Panel Closed","Panel Closed","","","","2024-04-18","Received letter the panel is closed. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Medicaid","Pending Other Enrollment","Pending Other Enrollment","","","","2024-05-21","Application request cancelled. Pending resolution of Dr. Wilson's enrollment with City of Midland. Jen Videan"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",45236,"00920011605","","2024-01-29","1/29/2024 Per UHC provider portal provider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00920011605.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-04","Location is not Tricare Credentialed. Panel is closed. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","United Health Care","In Process","Application Submitted","","","","2024-03-19","Submitted application via delegated monthly roster on 03/15/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Payor Follow Up","","","","2024-01-31","1/31/2024 Per USA PPO provider portal provider is still not loaded under new locations.  Will allow more time, check back in 2 weeks.  Sent follow-up email to LaNetrice Myart to check status of December roster submission.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","First Health Coventry","In Process","Application Submitted","","","","2024-03-15","3/15/2024 Submitted provider via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",45236,"008925217","","2024-01-23","1/23/2024  Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 11/6/2023.  MPIN # 008925217.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Enrollment Complete",45219,"","","2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Superior","Participating","Enrollment Complete",45383,"","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2024-05-22","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","PPHP","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (aprovence@pphealthplan.com) requesting update on enrollment status. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",45231,"6C4889","","2023-11-28","Provider is already enrolled with this group and locations. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Aetna","Participating","Enrollment Complete","2024-02-06","","","2024-05-20","5/20/2024- Spoke to Nica M call ref # 6192807041 provider participating as of 2/6/2026. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Triwest VA","Thru Other Payor","Thru Other Payor","","","","2024-03-19","Pending BCBSTX enrollment. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-12-01","0446524","","2023-12-04","Received approval email effective 12/01/23. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete",45236,"","","2024-04-11","4/11/2024 As per Cassandra (WellPoint rep) Dr. Bennion is par effective 11/6/2023. FC"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-11-05","Panel is closed to new providers until further notice. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-11-03","11/3/2023 CAQH profile maintained by practice.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-11-01","8096880","","2024-01-03","Received confirmation. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/6/2023. PA."]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2023-11-06","","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-11-06","","","2023-12-07","Provider is linked to the group eff 11/6/23. MS"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-11-06","008167479","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 008167479.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2023-11-06","","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 008167479.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Rcvd email confirmation from Jessica Bess at Multiplan that November roster has been processed and provider is PAR w/ group effective 11/6/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","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","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-08-01","4705 Briarwood: 08.01.2023 : S/W Gwen F of TriCare Standard @ 8004445445 transferred call to WPS dept and S/W Becky - provider is participating and certified under the group and TIN effective 07/28/2023. Provider ID is 473465832-79707-C002. Recred date is 02/28/2025. Physical location is on file. Call ref#Becky08012023. - Charmaine Pimentel"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider has been linked to Andrews Hwy location eff 10/26/23. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["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","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-01","008092273","","2024-01-30","1/30/2024 Rcvd email confirmation from UHC that January delegated roster has been completed.  Provider is PAR and linked to group/location effective 2/1/2024.  MPIN # 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-18","Received confirmation of enrollment. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-13","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-10-13","","","2024-05-02","Received email from Marcus Wester (mwester@humana.com) provider has been linked to location, eff. 10/13/2023. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2024-04-26","Sent email to Cassandra Dunagan- Smith requesting assistance with adding locations. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2022-05-01","Q00274901","","2022-06-11","Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00274901 - effective 5/1/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44725,"","","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",44682,"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",44682,"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",44682,"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",44682,"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","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-05-31","Pending Medicare approval. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-02-01","","","2024-05-10","Received email confirmation from shpdelegation@superiorhealthplan.com, provider is par and linked to TIN/location, eff. 02/01/2024. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2024-02-01","6819516","","2024-01-09","Received confirmation of enrollment. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","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","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 6819516 DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",45047,"","","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","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","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","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44533,"","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-12-03","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 12/3/2021.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","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","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024 location has been added, eff. 1/1/2020. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-18",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2023-09-01","","","2023-09-06","Rcvd approval letter from Dee Dee Johnson at Texas Mutual. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","Participating. Please see Alliance WC for notes. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",45047,"","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1841780806","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","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","Humana","In Process","Payor Follow Up","","","","2024-05-17","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-05-25","","","2024-04-25","4/25/2024 provider enrolled as of 5/25/2023 via roster. FC"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-18","App to update the group record has been submitted and is in processing. Once this has been approved, the providers record will automatically be updated at the same time. Nothing further is needed after that. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-10-02","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",44725,"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","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","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["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","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["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","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","Broadspire Services Inc.","In Process","Pending Other Enrollment",45440,"","","2024-06-03","Please see status updates under group record payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Enrollment on Hold","Enrollment on Hold","2024-05-28","","","2024-06-10","Pending site visit. Please see status updates under group record payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","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","HealthSmart PPO","Participating","Enrollment Complete","2022-06-13","","","2022-08-10","8/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-18","Group app to add this location has been submitted. Once approved, an ind. app to link the provider will need to be submitted. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["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",44743,"","","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",44743,"","","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","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","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2024-05-14","Pending group app approval. This was submitted 5/14/24. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Scott&White (First Care)","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Submitted","","","","2024-06-21","Location add pending under case#  09598462, per BCBSTX portal. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",44925,"","","2024-02-13","Provider effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",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"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Sedgwick","Participating","Enrollment Complete",45063,"","","2024-03-05"," Per spneast@sedgwickcms.com address has been added to provider's profile effective 05/17/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Pending Other Enrollment","2024-05-28","","","2024-06-18","Please see status updates under group record payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","No Value Specified","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-05-01","","","2023-07-24","Confirmed via online directory. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",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 Municipal League","Provider Load","Provider Load","2024-05-28","","","2024-05-28","new location"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge and 4705 Briarwood have been added to provider's profile. Effective dates are not given. 6301 Andrew Hwy cannot be added until a site visit is completed. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45201,"","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",44713,"","","","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 06/01/2022, and linked to 616 Main St. location. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-04-30","Sent email to lee.kinard@healthsmart.com and aleece.moerbe@healthsmart.com requesting enrollment status update. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44725,"000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44725,"000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","000008092273","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2022-09-23","9/23/2022 Per roster received from Joe Rodriguez at Amerigroup provider is PAR and linked to group TIN effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Pending Other Enrollment","2024-05-28","","","2024-06-10","Please see status updates under group record payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2022-06-13","00008092273024","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/13/2022.   MPIN# 008092273.   DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-12-30","","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",44925,"","","2022-09-21","Per Michelle Killough provider is effective 12/30/2022. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2024-02-13","Please see status updates under Alliance WC payor line. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Pending Other Enrollment","2024-05-28","","","2024-06-24","Please see status updates under group record payor line. Jen Videan"]
["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","Medicare","Participating","Enrollment Complete","2024-05-07","","","2024-04-30","Received confirmation the group enrollment record has been updated to show the Main St. location added eff 5/7/2024. The providers record is auto-updated to show the info as well. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["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","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","2022-06-13","","","2023-09-01","9/1/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",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","Omni PPO","Participating","Enrollment Complete",45047,"","","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",45047,"","","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",45047,"","","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","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2022-06-01","3567571","","2023-09-20","09.20.2023 S/W Ashnti of First Health @ 800-226-5116 and transferred me over to Courtney. Per rep, provider is in network with First Health for the state of TX and linked to the group and TIN# effective 06/01/2022. Next recredentialing date is on 06/01/2025. PIN: 3567571. Servicing location is on file. Payer# 73159. Call ref# 760029. - Willie Ravas"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",44725,"","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",45323,"","","2024-05-20","5/202/24 Spoke to Alex call ref#6192816326 616 N Main St  location participating as of 02/1/2024. FC"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Sedgwick","Participating","Enrollment Complete",44873,"","","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","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-05-31","Facility Enrollment. Providers services are billed through the facility, not an individual claim. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-06-19","6819516","","2023-09-19","09.19.2023 S/W Sofie of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 06/19/2023. Provider ID 6819516. Service location is on file. Call ref#:SofieS09192023."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","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","Amerigroup","Participating","Enrollment Complete","2022-06-13","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/13/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-18","Group enrollment has been submitted. If the payor wants to contract, they will reach back out and request a roster. There is no follow up needed. MS"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-05-01","","","2024-05-09","Received email from Marina Martinez of USA MCO, provider is PAR and 616 Main St location linked, eff. 05/01/2024."]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-12-19",""]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-02-01","","","2024-05-10","Received email confirmation from shpdelegation@superiorhealthplan.com, provider is par and linked to TIN/location, eff. 02/01/2024. PA"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45440,"","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-11-08","","","2023-08-29","Rcvd welcome letter from Karina Garcia at Corvel. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",44873,"","","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",44873,"","","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","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","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","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",45138,"","","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",45138,"","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-07-31","","","2023-08-01","Rcvd email from providerdata@careworks.com  request to add 3 new location is complete. Effective 7/31/2023. Jen Videan"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-12-30","","","2023-01-11","01/11/2023 - Received welcome letter confirming participation with PSWCA, eff. 12/30/2022.  DCannon"]
["Chisom Nwoye, MD",1841780806,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-29","Confirmed via the Coventry portal the provider is enrolled. MS"]
["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","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","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-04-14","","","2023-07-12","Received confirmation email from rep. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2023-05-19","","","2023-07-18","Michelle Killough confirmed provider is effective 5/19/2023. MS See Alliance for enrollment note updates."]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","In Process","Payor Follow Up","","","","2024-04-24","Allow 90+ days for credentialing from 03/13/2024. Still within 90+ timeframe...allow more time. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2023-04-14","","","2023-07-20","7/20/2023 Per email received from Galaxy April  delegated roster has been processed and provider is PAR and linked to group effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","In Process","Pending Contracting","","","","2024-04-23","See Broadspire under group record for updates. Jen Videan"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next roster submission. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","Participating","Enrollment Complete","2023-05-25","","","2024-04-25","4/25/2024 provider participating as of 5/25/2023 via roster. FC"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2023-04-25","","","2023-10-19","Received enrollment confirmation. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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","Wellmed","Participating","Enrollment Complete","2023-05-01","","","2023-12-28","12/28/2023 Per UHC web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete",45047,"","","2023-08-21","Received confirmation. 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","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","Humana","Participating","Enrollment Complete","2023-04-14","","","2023-09-19","9/19/2023 - Received email that delegation roster has been completed.  Provider is PAR and linked to group TIN/location effective 4/14/2023.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed on Coventry portal. Please add to next roster submission. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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","United Health Care","Participating","Enrollment Complete","2023-05-01","003614004","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 5/1/2023.  MPIN# 003614004.  DCannon"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2023-04-25","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Payor Follow Up","2023-04-14","","","2024-05-16","5/16/2024 Payor has incorrect address, updated address submitted via delegated roster on 5/15/2024. FC"]
["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","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","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","IMS","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Re-Credentialing","2023-04-14","","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M 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","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","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed in Coventry portal. Please add to next roster submission. MS"]
["Bethany M Wood, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-26","Not listed in Coventry portal. Please add to next roster submission. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete","2018-07-31","1740542034","460950925","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-09-20","1740542034","","2020-08-20","08/20/2020 - Rec'd emailed spreadsheet from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","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","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","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","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","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","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["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","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","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","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","Omni PPO","Participating","Enrollment Complete","2018-07-24","1740542034","","2020-06-26","06/26/2020 - EFF IF IMS IS EFF - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","First Health Coventry","Participating","Enrollment Complete",43313,"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","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","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","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","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","In House Enrollment","2020-01-05","412587401","325373401","2020-08-13","8/13/2020 - rec'd effective letter from the clinic. HOwever, this is not a payer that they asked Symplr to maintain. Created a payer line to house effective info if needed by another payer for enrollment - Stacey Hudak"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","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","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","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","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","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","Aetna","Participating","Enrollment Complete","2020-09-01","1346807278","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is now participating under group Tax ID effective 9/1/2020 and assigned PIN number 6962996. Kimberly Frazier"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","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","Amerigroup","Participating","Payor Follow Up","2020-04-15","","","2024-04-19","4/19/2024- Submitted for Medicaid products via delegated roster on 4/15/2024. FC"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-10-26","1649462987","475554737","2020-08-18","Confirmed provider is participating with PPO and H&W Networks (list of networks attached). Kimberly Frazier"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-05-21","","","2024-05-21","05/21/2024 CAQH Reattested updated and uploaded TX license wthompson"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete",43399,"1649462987","",44022,"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","Medicaid","Participating","Enrollment Complete","2018-08-01","387144401","364596201","2023-12-19","Revalidation approval letter rcvd. Effective 08/01/2018. Jen Videan"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","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","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","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","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","Amerigroup","Participating","Enrollment Complete","2018-11-30","1649462987","","2020-03-18","03/18/2020 - Rec'd confirmation from the payer via spreadsheet stating this provider is EFF with Amerigroup through Texas True Care - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","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","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","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","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","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","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","CAQH","Participating","CAQH Reattested",45440,"","","2024-05-28","05/28/2024 CAQH Reattested Updated and uploaded board all locations current wthompson"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","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",43313,"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","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"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete",43399,"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",43399,"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",44652,"","","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","Medicaid","Participating","Enrollment Complete",43344,"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","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","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","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","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","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","Boon Chapman","Participating","Enrollment Complete","2020-08-27","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 8/27/2020.  DCannon"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete",43435,"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","Scott&White (First Care)","Participating","Enrollment Complete",43399,"1407149883","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2024-03-11","","","2024-06-03","Per Aetna rep Irish G, 1-800-353-1232, reference #6194100173, provider is  PAR, effective 3/11/2024, linked to TIN and location. PA"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (hpdelegation@bswhealth.org) requesting update on enrollment status. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2024-02-12","7487489","","2024-04-05","Received confirmation of enrollment via email. MS"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-12","Location is not Tricare Credentialed, panel is closed. MS"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","In Process","Payor Follow Up","","","","2024-05-31","Sent follow-up email to previous inquiry. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-03-19","Pending UHC enrollment. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2024-03-12","","","2024-04-29","Provider is linked to this location eff 3/12/24. MS"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","In Process","Payor Follow Up","","","","2024-06-03","Application still pending, under task ID# PR-8228570, in process per UHC online representative Elizabeth, reference #04559992. PA."]
["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","Caprock (CapStar)","Participating","Re-Credentialing","2019-04-04","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","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","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","Re-Credentialing","2020-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested updated and uploaded Board. all locations current wthompson"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","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","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2024-04-25","Per Maria at maria.lightner@careworks.com, information has been rcvd and is in process. Allow 90+ days for credentialing. Still within 90+ timeframe...allow more time. Jen Videan"]
["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","First Health Coventry","Participating","Re-Credentialing",43586,"2650428","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","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","Aetna","Participating","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","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","Triwest VA","Participating","Enrollment Complete",44774,"","","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","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","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","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-04-27","1588857874","","2024-05-07","Provider active with Corvel. Jen Videan"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","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","IMS","Participating","Re-Credentialing","2019-05-21","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2019-04-19","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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","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","Amerigroup","Participating","Re-Credentialing","2021-02-12","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2019-05-31","1588857874","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","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","Broadspire Services Inc.","In Process","Pending Contracting","","","","2024-04-23","See Broadspire under group record for updates. Jen Videan"]
["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","Scott&White (First Care)","Participating","Enrollment Complete",43616,"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"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2019-02-18","779243","320497","2020-01-30","01/30/2020 - Found this provider is linked to Midland Texas Ortho (group PTAN 320497 and Employer ID# 1346681061) as of 2-18-2019. MAURENE.MCDANIEL@MIDLANDHEALTH.ORG  is the contact person - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Pending Other Enrollment","Pending Contracting","","","","2024-04-25","Per Maria at maria.lightner@careworks.com, information has been rcvd and is in process. Allow 90+ days for credentialing. Still within 90+ timeframe...allow more time. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2019-05-21","1164778767","","2020-07-17","07/17/2020 Received a spreadsheet from the payer stating this provider is effective as of 5/21/2019. – Archie Candiasan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2019-03-06","1164778767","","2020-02-20","02/20/2020 - Had the follow up team call CIgna to verify provider enrollment with this TIN. They were advised that this provider is EFF as of 3-6-2019 at this service location. They also said this provider IS DELEGATED; but could not say who the delegated company is. - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing","2021-02-12","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2019-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Humana","Participating","Enrollment Complete","2020-01-01","1164778767","","2020-07-19","7/19/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Re-Credentialing","2019-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","2014-01-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 1/1/2014. Kfrazier"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2019-02-18","362149203","331090601","2024-02-21","Rcvd revalidation approval ltr. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Re-Credentialing","2019-05-01","3039403","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Re-Credentialing","2019-05-31","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2020-05-01","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 5/1/2020.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2019-06-06","1164778767","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal. Provider is linked to group at this service location - Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2019-11-01","1164778767","463131679","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating at location and under TIN effective 11/1/2019.  DCannon"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-04-13","","","2020-10-02","10/2/2020 - Rec'd response from the payer stating \"•\tProviders marked as \" Delegated Contract With SHP” have an active delegated contract with another entity by the same NPI & TIN through Superior Health Plan. Please note that these providers will not be accepted as part of your Delegated Opt-in. \" \nWe cannot add this provider to the PriMed delegation, as they are already with another delegated group- Stacey Hudak"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","USA PPO","Participating","Enrollment Complete",43616,"1164778767","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2019-06-06","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","In Process","Pending Contracting","","","","2024-04-23","See Broadspire under group record for updates. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing","2020-05-21","1164778767","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","2014-01-01","","","2020-07-27","7/27/2020- S/W  Jack of  Gallagher (thru Coventry) @ 800-243-2336 and she transferred the call to cred dept. S/W  Lynn  and  she confirmed group is par with Worker's Comp Network under the TAX ID eff 1/1/2014.  Provider is  par as a delegated  with Worker's Comp Network under the TAX ID eff 5/1/2019. Physical location is on file. Group ID# 2559513 and Individual ID# 3039403. Call ref#181324888. - Elonah Grace B. Gelig"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2019-02-18","P02405660","","2020-03-25","3/25/2020- Per online check, provider is now PAR effective 02/18/2019 with provider number P02405660. Attached welcome letter to payor line\n-tisha rader"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2019-11-01","1164778767","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["Rachel K Longacre, APRN-FNP-BC",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, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-05-21","1639524861","","2020-06-25",""]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45440,"13859704","","2024-05-28","05/28/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Rachel K Longacre, APRN-FNP-BC",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, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2023-07-19","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/19/2023.  DCannon"]
["Rachel K Longacre, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-06","Location added under group record, but is not a Tricare Credentialed location. MS"]
["Rachel K Longacre, APRN-FNP-BC",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, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2024-05-22","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Rachel K Longacre, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Ste. 240. MS"]
["Rachel K Longacre, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2020-09-15","1639524861","","2020-09-22","09/22/2020 - Called 800-872-3862 but routed to Aetna Corporate Center and unable to reach live rep. Called Aetna @ 800-353-1232 S/W Mark. Provider NPI# is on file for the provider and is participating effective 09/15/2020 under the group and TIN#. Physical location is on file.Call Ref# 5560576876. - Archie Candiasan"]
["Rachel K Longacre, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-08-01","1639524861","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Rachel K Longacre, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-27","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is approved and participating under Group Tax ID and location effective 10/27/2020. Kimberly Frazier"]
["Rachel K Longacre, APRN-FNP-BC",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"]
["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","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","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","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["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","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","CAQH","Participating","CAQH Reattested","2024-06-03","","","2024-06-03","06/03/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["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","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","Aetna","Participating","Enrollment Complete","2020-09-01","6694913","","2020-11-24","11/24/2020 - Per f/u report provider NPI# is on file for the provider is linked and is participating effective 09/01/2020 under the group and TIN#. Provider ID 6694913. Group ID 4907135.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete","2019-08-26","1144665233","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete","2017-05-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Superior","Participating","Enrollment Complete","2019-10-01","1144665233","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","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","Medicaid","Participating","In House Enrollment","2019-09-01","404183201","","2020-06-29","06/29/2020 - client supplied us with copy of MEDICAID EFF letter for other payer enrollments, if needed. Symplr does not need to maintain this enrollment.  Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","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","IMS","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","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","Amerigroup","Participating","Enrollment Complete","2023-06-05","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","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","CAQH","Participating","CAQH Reattested","2024-05-28","13876531","","2024-05-28","05/28/2024 CAQH Reattested all locations current and updated and uploaded board wthompson"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-05-28","13876531","","2024-05-28","05/28/2024 CAQH Reattested all locations current and updated and uploaded board wthompson"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-05-28","13876531","","2024-05-28","05/28/2024 CAQH Reattested all locations current and updated and uploaded board wthompson"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-05-28","13876531","","2024-05-28","05/28/2024 CAQH Reattested all locations current and updated and uploaded board wthompson"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2019-07-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","IMS","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Participating","Enrollment Complete","2020-12-01","","","2023-03-24","03/17/2023- Per Triwest VA  email confirmation, provider participating under practice DCN, eff. 12/01/2020. PA"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-06-05","","","2023-09-07","9/7/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-06-01","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2023.  PID # 3002056.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2019-07-02","1932541406","","2020-09-14","Upon review of the Self-Service portal, provider is completed and loaded as participating under practice location. Kimberly Frazier"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2019-04-15","1932541406","","2020-07-30","7/30/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2023-06-05","","","2023-10-20","10/20/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2019-05-01","804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","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","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","Cigna","Participating","Enrollment Complete",45082,"","","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 Prime","Participating","Enrollment Complete","2023-08-11","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-06-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-05","","","2023-07-26","7/26/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","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","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","2023-07-20","","","2023-09-07","9/7/2023 Per email rcvd from Scott & White delegated roster for June has been completed.  Provider is PAR and linked to group TIN/location effective 7/20/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","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","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","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","Multiplan","Participating","Enrollment Complete","2019-07-20","1932541406","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 7-20-2019. Provider is networked with Beechstreet. - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","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","Caprock (CapStar)","Participating","Enrollment Complete","2019-06-12","1932541406","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","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","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","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","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-03","Rcvd revalidation approval ltr.  2402 W Wall effective 03/22/2023 and 4214 Andrews Hwy Ste 107 effective 08/21/2022. Jen Videan"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","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","HealthSmart PPO","Participating","Enrollment Complete","2023-06-05","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",43738,"1932541406","","2020-06-25",""]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-28","Revalidation approval ltr rcvd. Jen Videan"]
["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","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","Caprock (CapStar)","Participating","Enrollment Complete",43703,"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","Amerigroup","Participating","Enrollment Complete","2019-08-30","1811423981","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - rec'd email from the payer Multiplan/Texas True Choie stating that this effective info is true - Stacey Hudak"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-04-07","5847282","","2024-01-31","Received completion notice. MS"]
["Deborah A Frempong, APRN-FNP-BC",1811423981,"75-2656723","TX","PE - Premier Family Care, Inc","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","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","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","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","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","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","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","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","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","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","CAQH","Participating","Pending Info/Document",45203,"14074150","",45203,"10/04/2023 - Invalid Id and Password - Mkhan"]
["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","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","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"]
["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","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"]
["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","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","CAQH","Participating","Pending Info/Document",44935,"","","2023-06-05","6/5/2023-Invalid CAQH Login-kavello"]
["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","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","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","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","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","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"]
["Purshotham R Ginne, MD",1255584397,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete",43831,"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","First Health Coventry","Participating","Enrollment Complete",43617,"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",43647,"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","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","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","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","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"]
["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","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"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44044,"1528619525","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-04-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-05-28","14530139","","2024-05-28","05/28/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["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","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","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-03-25","Reactivation complete. Approval ltr rcvd. 2402 W Wall Street effective 02/26/2023. 4214 Andrews Hwy Ste. 240 Effective 10/01/2019. Jen Videan"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","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","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","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","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","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","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","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","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","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","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","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","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","TriCare Standard","Participating","Enrollment Complete","2020-04-02","1528619525","","2020-09-24","09/24/2020 - moved to completed after reviewing follow up complete - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2019-12-30","1528619525","","2020-02-20","02/20/2020 - Rec'd verification from the payer that this provider is EFF 12-30-2019 and linked to this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","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","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","HealthSmart PPO","Participating","Enrollment Complete","2019-12-11","13706552","","2020-07-21","07/21/2020 - Rec'd spreadsheet from the payer stating this provider/TIN/service location are PAR with WEST TEXAS PHYSICIANS ALLIANCE Delegated  - Stacey Hudak"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-28","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-09-26","Confirmed provider is linked to Briarwood and Longview locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-10-26","Confirmed Eastridge location effective 10/9/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-04","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Pending Other Enrollment","2024-05-30","","","2024-06-10","Please see status updates under group record payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","2024-06-06","","","2024-06-12","Application submitted. Request ID: 20443605. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","2024-06-06","","","2024-06-12","Application submitted. Request ID: 20443605. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","2024-06-06","","","2024-06-12","Application submitted. Request ID: 20443605. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","2024-06-06","","","2024-06-12","Application submitted. Request ID: 20443605. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","2024-06-06","","","2024-06-12","Application submitted. Request ID: 20443605. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","2024-06-06","","","2024-06-12","Application submitted. Request ID: 20443605. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","2024-06-06","","","2024-06-12","Application submitted. Request ID: 20443605. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Application Submitted","2024-06-06","","","2024-06-12","Application submitted. Request ID: 20443605. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-11-17","","","2024-02-13","Provider effective 11/17/2023. Alliance WC website only lists two locations per provider. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"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",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","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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",44785,"","","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","Rail Road Medicare","Provider Load","Provider Load",45449,"","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Provider Load","Provider Load",45449,"","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Provider Load","Provider Load",45449,"","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Provider Load","Provider Load",45449,"","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-01","6669419","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/01/2023. No next recredentialing date available. PIN: 6669419. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","2024-05-30","","","2024-05-30","Please see status updates under Alliance WC payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2022-09-08","9/8/2022 Rcvd RR Medicare approval letter.  PTAN # Q00322530 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","3637790","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/1/2023. Provider ID 3637790. Physical locations are on file. Call ref#:773026. - DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-11","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/11/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Pending Other Enrollment","2024-05-30","","","2024-06-03","Please see status updates under group record payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Provider Load","Application Submitted","2024-06-06","","","2024-06-17","4 applications submitted via online secure portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Provider Load","Application Submitted","2024-06-06","","","2024-06-17","4 applications submitted via online secure portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Provider Load","Application Submitted","2024-06-06","","","2024-06-17","4 applications submitted via online secure portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Provider Load","Application Submitted","2024-06-06","","","2024-06-17","4 applications submitted via online secure portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Provider Load","Application Submitted","2024-06-06","","","2024-06-17","4 applications submitted via online secure portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Provider Load","Application Submitted","2024-06-06","","","2024-06-17","4 applications submitted via online secure portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Provider Load","Application Submitted","2024-06-06","","","2024-06-17","4 applications submitted via online secure portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Provider Load","Application Submitted","2024-06-06","","","2024-06-17","4 applications submitted via online secure portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Provider Load","Provider Load","2024-05-30","","","2024-05-30","new location"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-04-30","Sent email to lee.kinard@healthsmart.com and aleece.moerbe@healthsmart.com requesting enrollment status update. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2022-11-15","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 11/15/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",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","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-05-01","","","2024-05-09","Received email from Marina Martinez of USA MCO, provider is PAR and 616 Main St location linked, eff. 05/01/2024."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-05-31","Facility Enrollment. Providers services are billed through the facility, not an individual claim. MS"]
["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",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,"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",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,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-08-12","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","2024-05-30","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-03-10","8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",44995,"8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",44995,"8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",44995,"8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",44995,"8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",44995,"8909854","","2023-10-03","10.03.2023 S/W Andrea of Cigna @ 1-800-882-4462. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/10/2023. Provider ID#:8909854. Service location is on file. Call ref#:Andrea10032023. - Danico Gabriel Melendres"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",45139,"Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","Q00596491","DX4335","2023-11-08","Enrollment completed via online portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45449,"","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45449,"","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45449,"","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45449,"","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45449,"","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45449,"","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45449,"","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45449,"","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45449,"","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45449,"","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-06-06","","","2024-06-06","06/06/2024 CAQH Reattested Added four locations wthompson"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Provider Load","Provider Load","2024-06-06","","","2024-06-06","new locations"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-17","Pending group record update. MS"]
["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","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4507 Santa Rosa is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4507 Santa Rosa is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste 103 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste 103 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","400 Rosalind Redfern Grover Pkwy., Ste. 230 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","400 Rosalind Redfern Grover Pkwy., Ste. 230 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste. 102 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste. 102 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4507 Santa Rosa is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4507 Santa Rosa is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste 103 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste 103 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","400 Rosalind Redfern Grover Pkwy., Ste. 230 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","400 Rosalind Redfern Grover Pkwy., Ste. 230 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste. 102 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste. 102 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4507 Santa Rosa is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4507 Santa Rosa is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste 103 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste 103 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","400 Rosalind Redfern Grover Pkwy., Ste. 230 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","400 Rosalind Redfern Grover Pkwy., Ste. 230 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste. 102 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste. 102 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4507 Santa Rosa is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4507 Santa Rosa is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste 103 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste 103 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","400 Rosalind Redfern Grover Pkwy., Ste. 230 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","400 Rosalind Redfern Grover Pkwy., Ste. 230 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste. 102 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","In Process","Pending Other Enrollment","","","","2024-06-17","4214 Andrews Hwy., Ste. 102 is Tricare Credentialed. Status can be viewed once the provider is added to this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Pending Other Enrollment","2024-05-30","","","2024-06-18","Please see status updates under group record payor line. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-09-15","Rcvd confirmation from providerrelations@primehealthservices.com provider has been loaded to roster, with effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2024-05-14","Pending group app approval. This was submitted 5/14/24. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-18","App to update the group record has been submitted and is in processing. Once this has been approved, the providers record will automatically be updated at the same time. Nothing further is needed after that. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-13","10/13/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45281,"","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3415 N Loop 250 W #4:provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","1805 S County Rd 1105: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3411 Caldera Blvd: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","5615 Deauville Ste 240: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","3620 N Big Spring St:  provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-25","4214 Andrews Hwy Ste. 107: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover: Provider is credentialed  and in network with this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","709 W Louisiana: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","2402 W Wall St: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","","","","2024-01-26","400 Rosalind Redfern Grover Ste. 120: provider is credentialed and is in network with Tricare at this location eff 7/20/2022. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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","Boon Chapman","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,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Provider Load","Provider Load",45442,"","","2024-05-30","new location"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45323,"","","2024-05-10","Received email confirmation from shpdelegation@superiorhealthplan.com, provider is par and linked to TIN/location, eff. 02/01/2024. PA"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45275,"","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45275,"","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45275,"","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45275,"","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-15","","","2023-12-19","Received email with Welcome letter effective 12/15/2023. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Payor Follow Up","","","","2024-06-21","Sent email requesting group roster from UHC. PA."]
["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",44816,"","","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",44816,"","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","6B4211","","2023-10-20","Received welcome letter. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-02","Confirmed with rep the Tricare medical/surgical provider panel is closed at this time. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["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",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","Omni PPO","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","Omni PPO","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","Omni PPO","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","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-08-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for August has been completed.  Provider is PAR and linked to group TIN effective 8/12/2022.   DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-17","Group contract has been submitted and if the payor decides to contract they will notify us and request a roster. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-01","","","2024-05-20","5/20/2024- Spoke to Audrey call ref#6192840042, 616 N Main St location participating as of 2/1/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-01","008193055","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-05-07","","","2024-04-30","Received confirmation the group enrollment record has been updated to show the Main St. location added eff 5/7/2024. The providers record is auto-updated to show the info as well. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-29",""]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-01","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1922658319","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"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,"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",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",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",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,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-01-03","Group holds an Ancillary contract which will bill for the midlevel services under the group. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-15","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-15","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-15","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-15","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-15","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-15","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-15","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-15","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"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,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-01","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-01","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-01","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-01","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-01","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-01","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-01","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",45170,"","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","In Process","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-06-12","Application in PE review. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-06-12","Application in PE review. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-06-12","Application in PE review. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-06-12","Application in PE review. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-01","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 09/01/2023, and linked to 616 Main St. location. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-12-05","Rcvd Welcome letter. Provider effective 11/17/2023. See status updates under Alliance WC payor line.  Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-12-05","Rcvd Welcome letter. Provider effective 11/17/2023. See status updates under Alliance WC payor line.  Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-12-05","Rcvd Welcome letter. Provider effective 11/17/2023. See status updates under Alliance WC payor line.  Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-12-05","Rcvd Welcome letter. Provider effective 11/17/2023. See status updates under Alliance WC payor line.  Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-12-05","Rcvd Welcome letter. Provider effective 11/17/2023. See status updates under Alliance WC payor line.  Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-12-05","Rcvd Welcome letter. Provider effective 11/17/2023. See status updates under Alliance WC payor line.  Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-12-05","Rcvd Welcome letter. Provider effective 11/17/2023. See status updates under Alliance WC payor line.  Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-12-05","Rcvd Welcome letter. Provider effective 11/17/2023. See status updates under Alliance WC payor line.  Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"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",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",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","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","No Value Specified","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-01-17","Per providerrelations@primehealthservices.comYour request has been received and being processed accordingly. However, at this time, I have no updates as to when the directory will be updated with the location add. \nPlease note, all Physicians/locations billing under the TIN you provided are subject to the terms of the PPO agreement and considered in network upon billing with the TIN.  Contract effective date 05/23/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2022-08-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-17","Location is not Tricare Credentialed  and the panel is closed to new providers, so there is nothing further needed. MS"]
["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","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,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-11-17","","","2023-11-27","Rcvd Welcome letter. Provider effective 11/17/2023. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Add Info Submitted","","","","2024-06-19","Payor requested effective date. This was submitted. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","In Process","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","In Process","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-08-28","2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",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","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-09-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-09-01","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/1/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-01","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/1/2023.  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","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"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,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2024-01-25","4214 Andrews Hwy Ste. 107: Confirmed provider is credentialed and in network with this location. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","In Process","Add Info Submitted","","","","2024-06-17","Submitted 4507 Santa Rosa, 4214 Andrews Hwy suite 102-103, and 400 Rosalind Redfern Grover Pkwy via delegated roster on 6/14/2024. FC"]
["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","Medicare","Participating","Enrollment Complete",44105,"1J2798","0008AH","2020-11-18","11/18/2020 - Rcvd notification from Novitas that Change of Information app has been approved.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2021-04-01","","","2021-03-24","3/19/21 (kstrickland) Called Atena SW Daniel Call Ref# 6008130068. He stated provider is in network but couldn't get me a provider ID bc they are waiting for the demographics team to load the date. It will take 30 days. But then you can call back to get a provider id.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2020-01-23","1276203","","2020-09-04","Confirmed provider is participating with PPO and H&W networks (see attached list of networks). Kimberly Frazier"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","United Health Care","Participating","Enrollment Complete","2016-01-02","1366762874","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","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","","First Health Coventry","Participating","Enrollment Complete",43952,"1366762874","","2020-06-12","06/12/2020 - Rec'd spreadsheet back stating this provider is EFF with the payer - PID# 2923799\n- Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2020-08-01","1366762874","","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Omni PPO","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-25",""]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-03","","","2024-06-03","06/03/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-02-17","","","2023-11-29","Per TMHP location has been approved. Effective 02/26/2023. Jen Videan"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicaid","Participating","Enrollment Complete","2022-08-07","","","2023-08-21","Stephanie Crawford  Medicaid par effective 08/07/22. Jen Videan"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2019-12-01","902816","TXB115966","2022-11-28","11/28/2022 Per PECOS provider is PAR and linked to group effective 12/1/2019.  PTAN # 902816.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2022-12-19","","","2023-01-20","1/20/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 12/19/2022.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2020-02-11","1B4358","320497","2020-04-23","04/23/2020 - Found porivder as EFF under gorup enrollment through PECOS - Stacey Hudak"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","2020-10-01","","","2021-08-06","8/6/2021 Moved to enrollment complete per notes from First Health/Coventry. Provider is effective 10/1/2020. KFrazier"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","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"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","In Process","Pending Contracting","","","","2024-04-23","See Broadspire under group record for updates. Jen Videan"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-05-30","12080988","","2024-05-30","05/30/2024 CAQH Reattested All locations current and all expirables up to date wthompson"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-09-28","154421503","079837301","2023-10-19","Welcome letter rcvd, revalidation complete. Jen Videan"]
["Cindy Marriner, FNP",1922008234,"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"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","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","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2014-11-01","P01415478","CE1588","2020-03-25","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2014 with provider number P01415478. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2014-12-01","1922008234","West Texas Physicians Alliance","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 Marriner, Cindy:\n\nNetwork:  MPI, MPI Auto and MPI WC\nNetwork Participation effective:12/01/2014 for Tax ID provided.\nContract Source Group contract through: 5026 - West Texas Physicians Alliance\n\nNetwork: PHCS\nNetwork Participation effective:12/01/2014 for Tax ID provided.\nContract Source Group contract through: 23655 - West Texas Physicians Alliance\n\nNetwork: Beech St.\nNetwork Participation effective:12/01/2014 for Tax ID provided.\nContract Source Group contract through: 52669 - West Texas Physicians Alliance\" - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1750796009","","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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-07-31","7/31/2021 This will be processed by group. KFrazier"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-08-28","3961479","","2020-09-01","09/01/2020 - moved to completed status after getting an email from the payer stating \"Your effective date is 08/28/2020. Your provider identification number is 3961479. \" - Stacey Hudak"]
["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","Cigna","Participating","Enrollment Complete","2020-08-28","3961479","","2020-09-01","09/01/2020 - moved to completed status after getting an email from the payer stating \"Your effective date is 08/28/2020. Your provider identification number is 3961479. \" - Stacey Hudak"]
["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","Scott&White (First Care)","Participating","Enrollment Complete","2021-06-01","","","2021-10-06","10/6/2021 Rcvd confirmaton email from S & W that July delegated roster has been complete and provider is PAR w/ TIN and location effective 6/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2018-02-28","1750796009","","2020-09-16","09/16/2020 - moved to complete status after reviewing spreadsheet from the payer stating the roster updates were done - stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2018-02-28","1750796009","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1750796009","","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"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2018-04-23","1750796009","","2020-10-05","enrolled thru PHCS"]
["Trinidad Marquez, FNP",1447701602,"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"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2017-04-01","1447701602","","2020-09-24","09/24/2020 - moved to enrollment complete status - Stacey Hudak"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Molina","Participating","Enrollment Complete","2018-08-03","","","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 8/3/2018.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2020-03-20","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 3/20/2020.  DCannon"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-07-31","7/31/2021 This will be processed by group. KFrazier"]
["Trinidad Marquez, FNP",1447701602,"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"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2021-04-10","","","2021-04-23","4/23/2021 Upon review of the self-service portal, provider is loaded as non-network under group location effective 4/10/2021. KFrazier"]
["Trinidad Marquez, FNP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete",44562,"","",45008,"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","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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2016-11-07","1154767234","","2020-09-09","09/09/2020 - Reviewed previous note and moved to completed status - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Rail Road Medicare","Participating","Enrollment Complete","2015-05-05","P02500765","DC8592","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through payer site - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2019-05-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/3/2019.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","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","Multiplan","Participating","Enrollment Complete","2016-07-26","","","2021-07-01","7/1/2021 Received roster from Multiplan confirming participation of providers with TIN /locations effective 07/26/2016.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","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","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete",42577,"","","2021-09-16","9/15/2021 Received roster from Multiplan listing provider as PAR under group TIN/location effective 7/26/2016.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-10-07","1154767234","","2020-10-30","10/30/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Oct 7, 2020 12:05:19 PM. Your request was assigned reference number PR-5533533 .\" - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2015-05-26","418117YM2M","00304W","2020-07-15","07/15/2020 - entered payer line to store Medicare EFF information, but this is maitained at the clinic - not by Symplr - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete",43515,"1891931341","","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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","","","2021-10-13","10/12/21 Received email from Mosley, Aldean D aldean_mosley@uhc.com, provider par at this location as of 12/1/2019. Cbankston"]
["Tonya Murphy, FNP",1891931341,"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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","","","2021-10-12","Received email from aldean_mosley@uhc.com, location par as of 12/1/19. Cbankston"]
["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","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","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","Cigna","Participating","Enrollment Complete","2019-09-01","5244447","","2020-05-13","05/13/2020 - rec'd email from the payer stating \"This is to confirm that your request has been completed.\" - Stacey Hudak"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","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","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","Humana","Participating","Enrollment Complete","2019-02-20","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/20/2019.  DCannon"]
["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","HealthSmart PPO","Participating","Enrollment Complete",43759,"","",44223,"1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 10/21/2019.  DCannon"]
["Michael Okoye, DO",1205299922,"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"]
["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","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"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2019-09-09","868716","00304W","2020-02-07","02/07/2020 - The payer list has indicated \"We credential our own Medicare\" - Stacey Hudak"]
["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","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","TriCare Standard","Participating","Enrollment Complete","2020-01-01","","","2020-12-04","12/4/2020 Confirmed provider is certified as non-network provider under group. KFrazier"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete",44501,"","",44896,"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","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","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-07-08","1184265050","","2020-07-21","07/21/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Jul 8, 2020 1:42:08 PM. Your request was assigned reference number PR-5374823 .\" - Demo update completed - Stacey Hudak"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete",44652,"","","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","Galaxy Health","Participating","Enrollment Complete",44348,"","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","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","Galaxy Health","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["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","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Jose Saucedo, FNP",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","Broadspire Services Inc.","In Process","Pending Contracting","","","","2024-04-23","See Broadspire under group record for updates. Jen Videan"]
["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","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","TX","PE - Midland Medicine PA","TriCare Standard","Participating","Enrollment Complete","2022-07-14","","","2022-07-21","7/21/2022 Per Tricare portal provider is PAR and linked to group TIN/ new location effective 7/14/2022.  DCannon"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-10-09","415097101","","2020-10-20","10/20/2020 - signed onto group TMHP account and found that this provider is now effective and linked to the group at this service location - Stacey Hudak"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2020-07-01","Q00513598","DW7662","2023-09-19","9/19/2023 Rcvd copy of RR Medicare approval letter from MQA.  Provider PTAN # Q00513598 effective 7/1/2020.  DCannon"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete",44222,"1312344","","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"]
["Suresh K Ravuri, MD",1750539268,"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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45323,"","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-12-21","12/21/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",43943,"","","2023-09-07","9/7/2023 Per email from UHC May delegated roster has been completed.  Provider is PAR and linked to group TIN/locations effective 4/22/2020.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2018-12-01","3191800","","2023-09-20","09.20.2023 S/W ShannonD of First Health @ 800-226-5116 and transferred me over to Melanie. Per rep, the provider is in network with First Health for the state of TX and linked to the group and TIN# effective 12/01/2018. No next recredentialing date available. PIN: 3191800. Servicing location is on file. No payer# available. No call ref# available. - Willie Ravas"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-02-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff. 02/01/2024. PA."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete",45345,"","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-10-19","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 10/19/2017.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-10-19","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 10/19/2017.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-08","Welcome ltr rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2020-04-15","","","2023-07-24","Confirmed via online directory. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-02-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 02/01/2024. PA."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/05/2023. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","First Health Coventry","In Process","Add Info Submitted","","","","2024-06-18","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["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","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-11","Provider is active at 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-11","Provider is active at 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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",43374,"","","2023-08-23","Provider is linked to group locations. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2018-10-01","715814","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 10/1/2018.  PID # 715814.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Provider Load","Provider Load","2024-05-29","","","2024-05-29","new location"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Superior","Participating","Enrollment Complete","2024-02-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 02/01/2024. PA."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Submitted","","","","2024-06-21","Location add pending under case#  09598462, per BCBSTX portal. PA."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Andrews Hwy linked eff 10.26.2023"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Andrews Hwy linked eff 10.26.2023"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete",42856,"","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 5/1/2017.  DCannon"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete",43957,"13727511","","2020-07-21","07/21/2020 - Rec'd emailed spreadsheet from the payer stating this provider/service location/TIN are EFF under WEST TEXAS PHYSICIANS ALLIANCE Delegated agreement - Stacey Hudak"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1215575576","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","HealthSmart PPO","Participating","Enrollment Complete",40575,"1518053149","","2020-06-10","06/10/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Cigna","Participating","Enrollment Complete","2019-09-01","","","2023-08-14","08.14.2023 S/W Sam of Cigna @ 1-800-882-4462, Provider is showing participating and link under the Group and TIN with an Effective date 09/01/2019. Provider ID 9763901. Service address is on file. Call ref#:SamB08142023.-Danico Gabriel Melendres"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","IMS","Participating","Enrollment Complete","2023-07-15","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","USA PPO","Participating","Enrollment Complete","2023-07-01","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","First Health Coventry","Participating","Enrollment Complete","2020-06-12","","","2023-10-09","10/9/2023 Rcvd email confirmation from Priscilla at MQA that provider effective date has been back dated to 6/12/2020 and the new location has been added.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","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"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Triwest VA","In Process","Application Submitted","","","","2024-02-23","Submitted request to add location via  BCBSTX portal, case# 08181755 (group profile) and case# 08181813 (provider profile).  Location needs to be added through BCBSTX network first prior to TriWest VA. PA."]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Sedgwick","Participating","Enrollment Complete","2021-01-26","","","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 1/26/2021.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2021-02-12","10499208","","2023-09-20","9/20/2023 Per email received from Amerigroup provider is PAR and linked to group TIN effective 2/12/2021.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","HealthSmart PPO","Participating","Enrollment Complete",44076,"","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 9/2/2020.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2020-08-24","1538571609","","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"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-07-17","04579869","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Participating","Enrollment Complete","","","","2024-02-01","Per Coventry portal provider is enrolled. Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2021-06-03","","","2021-09-14","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 6/3/2021 under the physical location. Provider ID is 26-3789190-79714-A016. Call ref# Herminia Gilongos"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Medicaid","Participating","Enrollment Complete","","363647401","","2020-10-01","10/01/2020 - Rec'd email from the clinic stating the TPI# only. NO effective date of TMHP group login info was shared. - 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","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-01","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Participating","Enrollment Complete","","","","2024-02-01","Per Coventry portal provider is enrolled. 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"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","Enrollment Stopped","Enrollment Stopped","","","","2024-01-16","Per Melody Starcher mstarcher@permianregional.com, Permian Physician Services and Andrews Family Medicine have  decided not to sign a contract  with Corvel. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Travelers WC","Participating","Enrollment Complete","","","","2024-01-27","Confirmed via the Coventry portal, the provider is enrolled. MS"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","Participating","Enrollment Complete","2017-08-01","","","2022-10-06","09/28/2022 -  Received Permian Physician Services roster from TriWest VA (Scarlett Abigail, Scarlett_Abigail@bcbstx.com); provider listed as participating, eff. 08/01/2017 | Priscilla A."]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2016-08-01","","","2024-02-28","Re-Cred completed eff 8/1/2016. MS"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","6163991","","2020-08-18","8/18/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Participating","Enrollment Complete","","","","2024-02-01","Per Coventry portal provider is enrolled. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","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","Sedgwick","Participating","Enrollment Complete","2024-04-17","","","2024-04-29","Rcvd acceptance letter. Provider effective 04/17/2024. Jen Videan"]
["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","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-01","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","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"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","1083867147","",44105,"10/01/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Medicare","Participating","Enrollment Complete","2017-02-20","560166YTA9","0A3812","2020-09-25","09/25/2020 - moved to completed status after reviewing PECOS EFF info from the clinic - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","Alliance WC","Participating","Enrollment Complete","2023-07-21","","","2023-09-01","Per Michelle Killough @ pswca provider effective 07/21/2023. Jen Videan"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2018-11-26","","","2021-04-28","4/28/2021 Confirmed via self-service portal, provider is participating under group Tax ID and practice location effective 11/26/2018. KFrazier"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2020-09-17","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective  9/17/2021. DCannon"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2019-11-01","","","2021-01-18","1/18/2021 - Per follow-up notes provider NPI# is on file for the provider and is participating effective 11/01/2019 for Commercial Choice, 08/02/2017 for Community and State and 06/01/2020 for Medicare under the group and TIN#.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2019-08-26",""]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"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"]
["Jennifer B Hada-Ondriezek, DPM",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"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-08-05","1972073906","Contract Source Individual","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 8/5/2020.  DCannon"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete",44622,"","","2024-03-06",""]
["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"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Re-Credentialing",44326,"","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",44326,"","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1720353592","","2020-08-21",""]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2014-04-01","","","2023-05-02","5/2.2023 Per confirm par status note.   Per rep, provider is showing participating with an effective date 4/1/2014 and link under the Group and TIN. Provider ID 2609103.  Service location is on file. Call ref#:610334. DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2020-06-22","","","2020-10-27","10/27/2020 Confirmed provider is certified as a non-network provider under group and Tax ID. Kimberly Frazier"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-26","1312291","","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"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Multiplan","Participating","Enrollment Complete","2020-08-05","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 8/5/2020.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-08-05","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 8/5/2020.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2020-10-01","1184035313","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the delegated primed roster - Stacey Hudak"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete",43709,"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"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2021-02-01","","","2021-03-08","3/8/2021 Rcvd confirmation from Cigna that provider is now participating under TIN and linked to location effective 2/1/2021.  CPID # 8550635.  DCannon"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete",44222,"1312312","","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"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2022-12-01","3628670","","2023-01-19","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 12/1/2022. Location is on file. Provider ID is 3628670. Next recredentialing date is every 3 years (12/1/2025) No information for the payer#. -Kim Monique Fabian"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1306928098","","2020-08-21",""]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","CAQH","Participating","CAQH Reattested","2024-05-30","","","2024-05-30","05/30/2024 CAQH Reattested all locations current, updated and uploaded board wthompson"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","HealthSmart PPO","Participating","Enrollment Complete","2011-11-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 11/01/2011.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","Medicaid","In House Enrollment","In House Enrollment","","","","2021-06-01","6/1/2021 Revalidation required mailing of original, which Chris Dalllaire of practice mailed directly to payor and forwarded us a signed copy for our files. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","Medicaid","Facility Enrollment","Facility Enrollment","","112273103","","2020-09-23"," 09/23/2020 - Rec'd email from the clinic with the group RHC TPI# 112273103.  Moved to effective status to bring payer line to a desired status. THIS IS A FACILITY ENROLLMENT - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-07-14","","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","Triwest VA","Participating","Enrollment Complete",44774,"","","2022-11-14","11/14/22 Per Scarlett Abigail TIN has active 400TX DCN.  TIN has association of RHC."]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","","Amerigroup","Participating","Enrollment Complete","2020-07-14","03829159","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","","","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete",42461,"1306928098","",44032,"07/20/2020 - moved to completed status after reviewing Follow Up Complete note. Provider has a DIRECT contract  - Stacey Hudak"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Participating","Enrollment Complete","2013-08-26","315563YSCJ","290001","2020-07-24","07/24/2020 - moved to completed status after confirming through group PECOS that this provider is linked to Part B Quick Care Clinic Group PTAN 290001. - Stacey Hudak"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2019-11-01","249667","","2020-09-08","09/08/2020 - Rev'd email rec'd from the payer and previous note - this provider is on file at this service location. Moved to completed status - Stacey Hudak"]
["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"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","United Health Care","Participating","Enrollment Complete","2020-10-29","754025","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 10/29/2020 and assigned provider ID 754025. KFrazier"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","First Health Coventry","Participating","Enrollment Complete","2022-12-01","","","2023-01-19","1.19.2023 S/W Britney of First Health @ 800-226-5116. Transferred the call and spoke with Courtney. Provider is on file and participating. Link under the group and TIN effective 12/1/2022. Location is on file. Provider ID is 3625881. Next recredentialing date is every 3 years (12/1/2025) No information for the payer#. -Kim Monique Fabian"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","Boon Chapman","Participating","Enrollment Complete","2020-08-21","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 8/21/2020.  DCannon"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2018-04-05","1285065946","","2020-08-26","08/26/2020 - moved to completed status after reviewing previous follow up complete note - Stacey Hudak"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2016-01-01","1285065946","","2020-08-19","8/19/2020 - Rec'd email from the payer stating this provider is already affiliated with the PRIMED DELEGATED AGREEMENT and linked to this TIN/Service Location. This provider is networked with;\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network  - Stacey Hudak"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",44179,"","","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","Superior","Participating","Enrollment Complete",44166,"","",44187,"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",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility 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"]
["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","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","USA PPO","Participating","Enrollment Complete","2021-01-26","1312371","","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","Cigna","Participating","Enrollment Complete",44239,"6320597","",44247,"2/20/2021 - Rcvd email from Cigna that provider has been approved effective 2/12/2021 PIN # 6320597.  DCannon"]
["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","HealthSmart PPO","Participating","Enrollment Complete","2020-10-13","","","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, APRN-NP",1194355339,"75-2656723","TX","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"]
["Rachel Ann Murphy, RD",1124637160,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-03-28","1124637160","","2023-05-10","5/10/2023 Rcvd TX Medicaid approval letter.  Provider is PAR and linked to group.  TPI # 1124637160 - effective 3/28/2023.  DCannon"]
["Rachel Ann Murphy, RD",1124637160,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2020-12-07","","","2021-01-06","1/6/2020 - Rcvd confirmation from payor that provider load is complete.  DCannon"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2021-03-03","0579169","",44263,"3/8/2021 Received email from discovercigna@information.cigna.com confirming provider is now enrolled with payor under Tax ID effective 3/3/2021 with assigned provider identification number 0579169. KFrazier"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2022-02-25","","","2022-03-09","3/9/2022 Per Tricare portal, provider is linked to location as of 2/25/2022. Cbankston"]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete",44224,"","","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, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Tricare Prime","Participating","Enrollment Complete","2022-08-18","","","2024-02-28","Re-Cred has been completed. eff 8/18/2022. MS"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2022-08-18","","",45350,"Re-Cred has been completed. eff 8/18/2022. MS"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","","","","2020-12-18","12/18/2020 This is an RHC facility and no enrollment is required. KFrazier"]
["Julie Parker, APRN-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,"74-2348334","TX","PE - Permian Gastroenterology PA","USA PPO","Participating","Enrollment Complete","2023-07-17","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 7/17/2023.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","CAQH","Provider Load","CAQH Reattested","2024-05-31","","","2024-05-31","05/31/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","Facility Enrollment","","","","","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-08","","","2021-03-24","3/24/2021 Rcvd confirmation email from hpcredentialinggroup@BSWHealth.org that provider is participating with TIN and location effective 03/08/2021.  DCannon"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-03","","","2024-06-03","06/03/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-03-10","2032079","","2021-03-11","3/11/2021 Received an email from discovercigna@information.cigna.com confirming provider has been approved and is participating under group Tax ID effective 3/10/2021 with assigned PIN 2032079. KFrazier"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jennifer Lynn Delk-Fikes, APRN-FNP-BC",1386288876,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","First Health Coventry","Participating","Enrollment Complete","2021-01-07","","","2023-06-02","06.02.2023 S/W Trina of First Health @ 800-226-5116. Rep advised to call aetna first to see if provider is credentialed with aetna. S/W Chris of Aetna @ 1-800-353-1232. Per rep, provider is showing participating with First Health and link under the Group and TIN with an Effective date 01/07/2021. Provider ID 6764140, Payer ID 60025 and Recredentialing date 01/07/2024. Service location is on file. Call ref#:6149441125. - Danico Gabriel Melendres"]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-07","1312391","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2021-09-02","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective 9/2/2021.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2021-02-17","","","2021-04-02","4/2/2021 Per Humana Millitary portal provider is certified and linked to TIN and location effective 2/17/2021.   Also rcvd approval letter confirming certification.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-02-08","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 02/08/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete",44235,"Q00052513","DW7662","2021-04-07","4/7/2021 Rcvd automatic approval of RR Medicare PTAN via web submittal.  PTAN # Q00052513 effective 2/8/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-03-15","","","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 3/15/2021. DCannon"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Re-Credentialing",44270,"","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2021-02-08","","","2023-07-28","Per TMHP request id 20202943 closed and approved. License has been updated. Jen Videan"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Re-Credentialing","2021-04-06","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Ambetter","Participating","Enrollment Complete","2022-12-01","","","2023-02-28","2/28/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Superior that provider is PAR and linked to group TIN/location effective 12/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2021-07-08","","","2024-02-28","Re-Cred has been completed. eff 7/8/2021. MS"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Re-Credentialing",44896,"","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Humana","Participating","Enrollment Complete","2022-12-01","","","2023-02-25","2/25/2023 Per email received from Vernita Young November delegated roster has been processed and provider is PAR effective 12/1/2022.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete","2021-04-05","2149846","","2021-11-19","11/19/2021 Rcvd email from Cigna that provider is PAR and linked to group TIN/location effective 4/5/2021.  CPID # 2149846.  DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Omni PPO","Participating","Re-Credentialing",44292,"","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","2024-06-11","","","2024-06-24","Application submitted via pswca.org. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","2024-06-11","","","2024-06-24","Application submitted via pswca.org. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-11","Group contract is being decided on. If they want to contract with this TIN, they will request a roster. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","2024-06-11","","","2024-06-18","Emailed roster to brandhi_wilson-woods@corvel.com. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Payor Follow Up","2024-06-20","","","2024-06-18","Received email confirmation provider is now par with BCBSTX, eff. 6/20/2024, participating in the following networks:\n\nBAV - Blue Advantage HMO\t\nBCA - BlueChoice PPO\t\nHME - Health Select\t\nHMO - Blue Essentials\t\nPMC - Medicare Advantage PPO"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2024-06-11","","","2024-06-11","Panel is closed to new enrollments. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2024-06-11","","","2024-06-11","Panel is closed to new enrollments. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2024-06-11","","","2024-06-11","Panel is closed to new enrollments. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete",45454,"5155848","","2024-06-11","This is a facility contract, so midlevels will bill services under the group instead of individual. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted",45454,"","","2024-06-18","Emailed roster to updates@primehealthservices.com. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Pending Info/Document","2024-06-11","","","2024-06-24","Missing Sedgwick forms. Emailed MQA for assistance. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Pending Info/Document","2024-06-11","","","2024-06-24","Missing Texas Mutal forms. Emailed MQA for assistance. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Pending Info/Document",45454,"","","2024-06-24","Missing Texas Mutal forms. Emailed MQA for assistance. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-17","The Yukon location is pending the group record to be updated to show the location as loaded. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Pending Other Enrollment","Enrollment Complete","","","","2024-06-17","Provider has been loaded to 5/6 locations. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Pending Other Enrollment","Enrollment Complete","","","","2024-06-17","Provider has been loaded to 5/6 locations. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2024-06-13","","","2024-06-10","06/10/2024 CAQH Sweep Added six locations, one license, COI, cred contact, and updated board, uploaded docs wthompson"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-11","Pending Medicare approval. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-11","Pending Medicare approval. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-05-10","6S4338","423838","2024-06-17","Received welcome letter. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","2024-06-11","","","2024-06-11","Please see status updates under Alliance WC payor line. Jen Videan"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing",44326,"","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete",44326,"","","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"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Re-Credentialing","2021-05-10","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2022-03-23","","","2022-06-11","6/11/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 3/23/2022.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2021-05-10","","","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",1417309105,"75-2656723","TX","","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","","Omni PPO","Participating","Re-Credentialing","2021-05-10","","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","Medicare","Participating","Enrollment Complete",44378,"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",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44326,"","","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, APRN-FNP-BC",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","United Health Care","Participating","Enrollment Complete","2023-12-11","00006112311","","2024-01-22","1/22/2024 Per UHC portal provider is PAR and linked to group TIN/location effective 12/11/2023. MPIN# 00006112311.  DCannon"]
["Kristin M Moose, APRN-FNP-BC",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Amerigroup","Participating","Enrollment Complete","2024-05-23","","","2024-06-19","As per May WellPoint roster, Andrews Hwy location eff as of 5/23/2024. FC"]
["Emily N Baker Butler",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Add Info Submitted","2021-08-09","","","2024-04-19","4/19/2024- Submitted new last name via delegated roster on 4/15/2024. FC"]
["Emily N Baker Butler",1053817940,"75-2656723","TX","","Medicare","Participating","Pending Medicare","","","","2024-06-17","Medicare is rejecting the request to update last name to Baker Butler. They are stating the NPPES isn't matching. MS"]
["Emily N Baker Butler",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-04-16","Pending Medicare approval. MS"]
["Emily N Baker Butler",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-02-08","7739275","","2022-05-20","5/20/2022 Per follow-up email from UHC on 2/24/2022 provider is par and linked to group TIN/location effective 2/8/2022.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-12-20",""]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-12-20",""]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Provider Load","Provider Load","2024-05-29","","","2024-05-29","new location"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-05-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 5/1/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-19","Eastridge eff 10/9/23, Briarwood eff. 10/9/23 and Longview eff. 7/10/21 locations are all approved. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-10-19","Eastridge eff 10/9/23, Briarwood eff. 10/9/23 and Longview eff. 7/10/21 locations are all approved. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Revalidation completed. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2021-10-08","","","2024-02-15","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Pending Other Enrollment","2024-05-29","","","2024-06-18","Please see status updates under group record payor line. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-18","App to update the group record has been submitted and is in processing. Once this has been approved, the providers record will automatically be updated at the same time. Nothing further is needed after that. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","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","Galaxy Health","Participating","Enrollment Complete",45201,"","",45188,"9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2019-04-29","113460785","","2022-05-17","5/17/2022 Per follow-up note on 5/11/2022 - S/w Joel of Coventry @ 800-937-6824. Provider NPI# is on file for the provider and is participating effective 04/29/2019  under the group and TIN#. Physical location is on file. PIN: 113460785. Call ref# 09583799. DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-01","007017728","","2024-01-30","1/30/2024 Rcvd email confirmation from UHC that January delegated roster has been completed.  Provider is PAR and linked to group/location effective 2/1/2024.  MPIN # 007017728.   DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2020-07-16","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 7/16/2020.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",44421,"","","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","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","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-03-29","","","2024-05-29","incorrrect username and password"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45183,"","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-09-01","3642314","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 9/1/2021.  PID #3642314.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-12-06","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 12/06/2021. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1851865067","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","2024-05-29","","","2024-05-29","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-04-18","","","2024-04-22","Approval ltr rcvd. Provider effective 04/18/2024. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-01","","","2024-05-20","5/202/24 Spoke to Alex call ref#6192816326 616 N Main St  location participating as of 02/1/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","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"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-01-03","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","TriCare Standard","Participating","Enrollment Complete","2021-12-14","","","2021-12-14","12/14/2021 Per Tricare portal, provider is eff 12.14.2021. Cbankston"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Superior","Participating","Enrollment Complete","2023-04-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new group TIN via group delegated roster effective 4/1/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"54-2080139","TX","PE - Sari Nabulsi, MD, LTD, LLP","HealthSmart PPO","Participating","Enrollment Complete","2021-08-13","","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/13/2021.  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","Caprock (CapStar)","Participating","Enrollment Complete","2021-08-26","","","2021-09-17","9/17/2021 Rcvd email from CapRock that monthly delegated roster has been loaded and the provider is PAR and linked to group TIN/location effective 8/26/2021.  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","Boon Chapman","Participating","Enrollment Complete",45083,"","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/6/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","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","Medicare","Participating","Enrollment Complete","2022-07-12","2G2470","0008AH","2023-07-19","7/19/2023 Per PECOS provider is PAR and linked to group and location 4214 Andrews Hwy, Ste. 102.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-07-12","2G2470","0008AH","2023-07-19","7/19/2023 Per PECOS provider is PAR and linked to group and location 4214 Andrews Hwy, Ste. 102.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-07-20","","","2024-04-29","Provider is approved and linked to this location eff 7/20/2022. MS"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44774,"","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 8/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2021-11-18","","","2022-04-21","4/21/2022 Per email received from VYoung at Humana delegated roster for December has been completed and providers loaded in Humana effective 11/18/2021.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2021-11-01","12182506","","2022-03-25","3/25/2022 Per Amerigroup online directory provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2021-11-01","","","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 11/1/2021.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete",44484,"","","2021-11-03","11/3/2021 Per follow-up notes.  Provider NPI# is on file for the provider and is participating effective 10/15/2021 under the group and TIN#. Physical location is on file. Call ref# 14237329.  DCannon"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2021-10-27","0227001","","2021-10-28","10/28/21 Received email from DiscoverCigna@information.cigna.com, application to participate in the Cigna network has been approved. Effective date is 10/27/2021. Provider identification number is 0227001 Cbankston"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2021-11-08","","","2021-10-26","10/26/2021 Received an email from swhpexpedites@bswhealth.org confirming provider is participating effective 11/8/2021 and requested we allow 4-6 weeks before submitting claims to ensure she is fully loaded in their systems.  KFrazier"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete",44525,"","","2021-12-13","12/13/2021 Rcvd email from UHC that provider is PAR and linked to group TIN/location effective 11/26/2021.  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","Humana","Participating","Enrollment Complete","2021-11-18","","","2022-04-21","4/21/2022 Per email received from VYoung at Humana delegated roster for December has been completed and providers loaded in Humana effective 11/18/2021.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2022-01-10","","","2022-06-19","6/19/2022 Per email received from Priscilla Albertine at MQA from a follow-up email she received from Humana provider is PAR and linked to group TIN effective 1/10/2022.  DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete","2022-01-15","7054828","","2022-02-24","2/24/2022 Per follow-up note from 2/18/2022 Provider NPI# is on file for the provider and is participating effective 01/15/22 under the group and TIN#. PIN 7054828. Physical location is on file. Ref# 6075529088. -DCannon"]
["Venkatasubbaraya Achanta, MD",1780693648,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2008-05-01","","","2022-04-23","4/23/2022 - Per follow-up note - Provider is on file and participating effective 5/1/2008 under the Group and TIN.  Physical location is on file.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-28","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Omni PPO","Participating","Enrollment Complete",45177,"","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Mutual","Participating","Enrollment Complete",45231,"","","2023-11-14","Approval Ltr rcvd. Provider effective 11/01/2023. Jen Videan"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2024-06-04","","","2024-06-04","06/04/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2022-12-14","","","2024-02-28","Re-Cred has been completed. eff 12/14/22. MS"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-14","7/14/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 5/9/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2021-12-01","","","2022-06-08","6/8/2022 Rcvd email that initial delegated provider load has been completed and ALL MQA providers are loaded under delegation with original effective date requested.  Provider is PAR effective 12/1/2022.  DCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","Medicare","Facility Enrollment","Facility Enrollment","","","","2022-02-17","2/17/2022 This is an RHC location and providers cannot be enrolled/linked to this location. Therefore no enrollment is required.  DCannon"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","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"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2021-01-01","1588983134","","2022-09-07","9/7/2022 Per TMHP web portal provider is PAR and linked to group effective 1/1/2021.  TPI # 1588983134.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","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"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2012-06-15","1619130929","","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",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-04","","","2024-06-04","06/04/2024 CAQH REattested all locations current and all expirables up to date wthompson"]
["Claude B Nguyen, MD",1619130929,"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"]
["Claude B Nguyen, MD",1619130929,"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"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-23","","","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",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-04-11","","","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"]
["Elena Krendelshchikova, NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","In Process","Payor Follow Up","","","","2023-06-05","6.5.23 Sent email to joe.rodriguez@amerigroup.com requesting update on status of delegated providers. ABoles"]
["Elena Krendelshchikova, NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","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"]
["Elena Krendelshchikova, NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","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"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Amerigroup","Participating","Enrollment Complete","2022-05-09","","","2022-11-16","11/16/2022 Per email received from Joe Rodriguez 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","Superior","Participating","Enrollment Complete","2022-06-01","","","2022-06-01","6/1/2022 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 6/1/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","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"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","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"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","USA PPO","Participating","Enrollment Complete","2022-05-09","","","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 5/9/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"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"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-07-01","008051513","","2022-08-10","8/10/2022 Rcvd email from UHC that July monthly delegation roster has been completed and provider is PAR and linked to group TIN effective 7/1/2022.  MPIN # 008051513  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-13","","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/13/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-07-01","","","2022-08-18","8/18/2022 Rcvd email from Cigna that provider is PAR and linked to group TIN/locations effective 7/1/2022.  PID# 2017438.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2021-07-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 7/1/2022.  DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"47-5554737","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45447,"","","2024-06-04","06/04/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-07-01","","","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 7/1/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete",44820,"","","2022-09-27","9/27/2022 Rcvd PSWCA - Alliance approval letter.  Provider is PAR and linked to group TIN effective 9/16/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-26","TIN is delegated. Confirmed enrollment via Coventry Portal. MS"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete","","","","2024-01-26","TIN is delegated. Confirmed enrollment via Coventry Portal. MS"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete","2022-03-14","2D2395","320497","2022-05-06","5/6/2022 Rcvd Medicare approval letter.  PTAN # 2D2395 - effective 3/14/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-08-09","","","2022-08-09","8/9/2022 Rcvd Corvel approval letter.  Provider is PAR and linked to group TIN/locations effective 8/9/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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","Tricare Prime","Participating","Enrollment Complete","2022-10-01","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["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","United Health Care","Participating","Enrollment Complete","2022-05-09","007929415","","2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 5/9/2022.   MPIN# 007929415.   DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","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","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",44690,"","","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","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","Scott&White (First Care)","Participating","Enrollment Complete",44690,"","","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","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","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","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","Multiplan","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2022-05-09","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-06-29","","","2022-07-14","7/14/2022 Per Humana Military provider portal provider is PAR and linked to group TIN/location effective 6/29/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","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","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","Cigna","Participating","Enrollment Complete",44656,"6841061","","2022-06-21","6/21/2022 Per follow-up note - NPI# for the provider is on file shows link and Par under the group and TIN# effective 4/5/2022, the physical location is on file and the Provider ID is 6841061.  Call ref # Angel6142022. - DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete",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","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","Aetna","Participating","Enrollment Complete",44690,"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"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","IMS","Participating","Enrollment Complete",44732,"","","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","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","","Humana","Participating","Enrollment Complete",44732,"","","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"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Medicaid","Participating","Enrollment Complete",44682,"","","2024-01-31","Provider was added during group enrollment. Provider is active with Medicaid, effective 05/01/2022. Jen Videan"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Cigna Healthspring","Panel Closed","Panel Closed","","","","2024-04-09","Received panel closed letter. MS"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Aetna","Participating","Enrollment Complete","2022-06-20","","","2023-04-11","4/11/2023 Rcvd email from Priscilla Albertine at MQA provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","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","PE - Premier Family Care, Inc","IMS","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"]
["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","Multiplan","Participating","Enrollment Complete","2022-09-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete",44816,"","","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",1568704971,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2022-06-20","","","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",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-07-18","1568704971","","2022-08-22","8/22/2022 Per TX Medicaid web portal, provider is PAR and linked to group effective 7/18/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2022-08-01","","","2022-08-10","8/10/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","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","","Ambetter","Participating","Enrollment Complete",44774,"","","2022-08-10","8/10/2022 Per roster received from Superior May monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","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\\"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-09-26","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/26/2022.   DCannon"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","8355571","","2022-11-30","11/30/2022 Per follow-up note - Per rep, provider is on file and participating. Link under the group and TIN effective 11/15/2022. Location is on file. Provider ID is 8355571. Next recredentialing date is 11/4/2025.  DCannon"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","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","TriCare Standard","Participating","Enrollment Complete","2022-09-23","","","2023-01-05","1/5/2023 Per Humana Military/Tricare portal provider is now a PAR Tricare Certified provider effective 9/23/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Rail Road Medicare","Participating","Enrollment Complete","2023-01-25","P02703383","","2023-08-21","Confirmed enrollment. MS"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Amerigroup","Participating","Enrollment Complete","2022-08-09","","","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 08/09/2022 and link under the Group and TIN. Provider ID 14467387, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-166745338. -DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2022-05-07","2H3685","0008AH","2022-08-18","8/18/2022 Rcvd Medicare approval letter.  PTAN # 2H3685 - effective 5/7/2022.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-06-04","","","2024-06-04","06/04/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Hannah Heflin, RD",1366172579,"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"]
["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","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","First Health Coventry","Participating","Enrollment Complete","2022-11-01","","","2023-02-15","02.15.2023 S/W Shannon of First Health @800-226-5116. Per rep, provider is in network and linked under the TIN effective 11/01/2022. Don't have next recredentialing date. Provider ID# 1972946648. Physical location is on file. Don't have payer#. Unable to obtain call ref# since rep transferred me to a different department. - Mary Rose Acebedo"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-08-29","","","2022-11-04","11.04.2022 Per follow-up note - S/W Chealse of Amerigroup @ 800-454-3730. Per rep, provider is showing participating with an  Effective date 08/29/2022 and link under the Group and TIN. Provider ID 14501240, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-166745338.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2022-08-29","","","2022-11-04","11.04.2022 Per follow-up note - S/W Chealse of Amerigroup @ 800-454-3730. Per rep, provider is showing participating with an  Effective date 08/29/2022 and link under the Group and TIN. Provider ID 14501240, Payer ID 26375 and No Recredentialing date. Service location is on file. Call ref#:I-166745338.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","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","Multiplan","Participating","Enrollment Complete","2022-08-29","","","2023-03-10","3/10/2023 Per email from Priscilla Albertine at MQA, she received confirmation from Multiplan that provider is PAR and linked to group TIN/locations effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete","2022-08-29","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2022-08-29","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.   DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-10-01","","","2022-12-19","12/19/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2022-10-01","","","2022-12-19","12/19/2022 Rcvd email from Priscilla Albertine at MQA w/ confirmation from Superior that provider is PAR and linked to group effective 10/01/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-08-29","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-08-29","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","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","Galaxy Health","Participating","Enrollment Complete","2022-08-29","","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete",44802,"","",44866,"11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/29/2022.  DCannon"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2022-09-08","","","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","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","Tricare Prime","Panel Closed","Panel Closed","","","","2024-02-13","all locations - panel closed, locations are not prime credentialed. MS"]
["Mark Stevens Clee, MD",1972946648,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["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","TriCare Standard","Participating","Enrollment Complete",44818,"","","2022-10-28","10/28/2022 Per Tricare/Humana Military portal provider is PAR and linked to group TIN/location effective 9/14/2022.  DCannon"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",44844,"","","2022-12-29","12/29/2022 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 10/10/2022.  DCannon"]
["Christian A Richardson, APRN-FNP-BC",1184261950,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-10-10","","","2022-11-28","11/28/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 10/10/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-08-23",""]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","IMS","Participating","Enrollment Complete","2022-09-26","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 9/26/2022.   DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2022-09-26","","","2022-11-28","11/28/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Aetna","Participating","Enrollment Complete","2023-01-01","","","2023-01-18","1.18.2023 S/W Dan of Aetna @ 800-353-1232. Provider is on file and participating. Link under the group and TIN effective 1/15/2023. Location is on file. Provider ID is 6836243. Next recredentialing date is 12/9/2025. Payer# is 60054. -Kim Monique Fabian\n-"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2023-01-15","","","2023-01-18","1.18.2023 S/W Dan of Aetna @ 800-353-1232. Provider is on file and participating. Link under the group and TIN effective 1/15/2023. Location is on file. Provider ID is 6836243. Next recredentialing date is 12/9/2025. Payer# is 60054. -Kim Monique Fabian"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2024-06-04","","","2024-06-04","06/04/2024 CAQH Reattested All locations current and all expirables up to date wthompson"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2022-09-26","","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA provider is PAR and linked to group TIN/location effective 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2022-11-01","","","2022-12-08","12/08/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted",44893,"","","2024-04-15","4/15/2024 New location added to delegated roster. FC"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45443,"","","2024-05-31","05/31/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-03-01","","","2023-08-31","8/31/2023 Per email from Marcus Wester at Humana January delegated roster has been completed and provider is PAR effective 3/1/2023.  DCannon"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45218,"","","2023-10-23","Received enrollment confirmation email. MS"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-03-01","","","2023-05-24",""]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-31","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from November has been completed and provider is PAR effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2022-12-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-10-06","5935530","","2023-09-21","09.21.2023 S/W Dennisse of Cigna @ 1-800-882-4462. Per rep, provider is part of a behavioral program then rep advised to call the behavioral dept at 800-274-4573. Called Cigna's behavioral dept @ 800-274-4573 then S/W Heba. As per rep, provider is showing participating and link under the Group and TIN with an Effective date 02/02/2023. Provider ID 5935530. Service location is on file. Call ref#:HebaH09212023. - Danico Gabriel Melendres"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2022-10-31","","","2022-12-29","12/29/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","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","2022-10-31","","","2022-11-21","11/21/2022 Rcvd email from Caprock that November Delegation roster provider load has been completed.  Provider is PAR and linked to group effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-10-31","","","2022-12-15","12.15.22 Called Aetna @800.353.1232 and spoke with rep. Gelo who confirmed provider is participating effective 10/31/2022 at service locations and Tax ID. No recred date given per rep. Provider # 8624593. Call ref# 6124264748. ABoles"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2022-10-31","","","2022-12-15","12.15.22 Called Aetna @800.353.1232 and spoke with rep. Gelo who confirmed provider is participating effective 10/31/2022 at service locations and Tax ID. No recred date given per rep. Provider # 8624593. Call ref# 6124264748. ABoles"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicaid","In House Enrollment","In House Enrollment","","","","2022-10-04",""]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete",44865,"008256523","","2023-09-05","9/5/2023 Per follow-up email from UHC provider is PAR and linked to group/location effective 10/31/2022.  MPIN#  008256523\n DCannon"]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 12/11/2023 and linked to TIN."]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Aetna","Participating","Enrollment Complete",45271,"","","2024-01-22","1/22/2024 Per Aetna online portal provider is PAR and linked to group TIN/locations effective 12/11/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45322,"","","2024-02-01","Received welcome letter. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2024-05-22","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2024-05-10","Emailed spneast@sedgwickcms.com for status. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","","","","2024-05-10","Emailed spneast@sedgwickcms.com for status. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-07","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-07","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-22","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023 Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-22","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023 Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-15","","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-07","9/7/2023 Panel is closed for enrollment.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-07","9/7/2023 Panel is closed for enrollment.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",45176,"","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/7/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-15","Sacha Stanley, NP added to contract with WesTex with an effective date of 5/23/23. \nJen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-01","","","2023-12-18","See status updates under Alliance WC payor line. Jen Videan"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 04/01/2024. PA."]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-07","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/7/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45177,"","","2024-04-25","Per Amerigroup roster, provider is PAR, eff. 09/08/2023; locations linked: 210 W Longview, 6301 Andrews, 6950 Eastridge Rd, and 4705 Briarwood Ave. PA."]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","In Process","Payor Follow Up","","","","2024-04-24","Application pending, case# PR-8204087 assigned. PA."]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-03-19","Pending UHC enrollment. PA"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","",45321,"Check Coventry portal for enrollment status. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","",45321,"Check Coventry portal for enrollment status. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-06-01","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-06-01","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed provider is linked to Longview location effective 9/20/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed provider is linked to Longview location effective 9/20/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location has been confirmed eff 10/9/23. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed provider is linked to Briarwood location effective 9/20/2023. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-04-30","Sent email to lee.kinard@healthsmart.com and aleece.moerbe@healthsmart.com requesting enrollment status update. PA."]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Add Info Submitted","","","","2024-06-18","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check enrollment status on Coventry portal. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-19","","","","Received confirmation provider is enrolled and participating with the following networks, eff. 10/19/2023:\nBAV - Blue Advantage HMO\t,\nHME - Health Select,\nBCA - BlueChoice PPO,\nHMO - Blue Essentials, and\nPMC - Medicare Advantage PPO\t\n- PA"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2024-02-10","Q00724982","","2024-04-25","Received confirmation of enrollment. MS"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-07","8439204","","2023-10-24","10.24.2023 S/W Julie of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 09/07/2023. No next recredentialing date available. PIN: 8439204. Servicing location is on file. Payer# 60054. Call ref# 6167809743. - Willie Ravas"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete",45170,"","","2024-04-25","4/25/2024 provider enrolled as of 9/1/2023 via roster. FC"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete",45170,"","","2024-04-25","4/25/2024 provider enrolled as of 9/1/2023 via roster. FC"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1538714076","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-08-25","8/25/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45441,"","","2024-05-29","05/29/2024 CAQH Reattested added one location"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45047,"","","2023-08-25","8/25/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-08-25","8/25/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45016,"","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 3/31/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45016,"","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 3/31/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an active ancillary contract, so credentialing for midlevels isn't required. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-05-25","","","2024-04-25","4/25/2024 provider enrolled as of 5/25/2023 via roster. FC"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-06-26","007726107","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 6/26/2023.  MPIN # 007726107.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Corvel Healthcare Corp.","In Process","Pending Other Enrollment","2024-05-29","","","2024-06-10","Please see status updates under group record payor line. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","3592528","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Stephanie Powell. Effective 12/05/2023. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Stephanie Powell. Effective 12/05/2023. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-01","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, so no credentialing is required for midlevels. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, so no credentialing is required for midlevels. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-06-26","007726107","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 6/26/2023.  MPIN # 007726107.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment updates. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","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","BCBSTX","Participating","Enrollment Complete",45135,"","","2023-07-31","07/31/2023 - Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO, Medicare Advantage PPO and Health Select, effective 07/28/2023. PA."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45135,"","","2023-07-31","07/31/2023 - Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO, Medicare Advantage PPO and Health Select, effective 07/28/2023. PA."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",45103,"00726107","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 6/26/2023.  MPIN # 007726107.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-06-26","00726107","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 6/26/2023.  MPIN # 007726107.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","6950 Eastridge Rd Odessa, TX 79765, 4705 Briarwood Ave Midland, TX 79707 and 210 West Longview Avenue Suite A Building A\nMidland, TX 79701 effective 08/01/2023. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-14","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/14/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-09-06","Rcvd approval letter from Karina Garcia. Effective 08/21/2023 for 210 W Longview, 4705 Briarwood and 6950 Eastridge. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","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","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-24","Per Benjamin Richbourg, roster has been successfully loaded. They do not have effective dates for individual providers. The only effective date is the one on the contract. For this contract effective date is 05/23/2023. Jen Videan"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-24","Per Benjamin Richbourg, roster has been successfully loaded. They do not have effective dates for individual providers. The only effective date is the one on the contract. For this contract effective date is 05/23/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-01","007509811","","2024-01-30","1/30/2024 Rcvd email confirmation from UHC that January delegated roster has been completed.  Provider is PAR and linked to group/location effective 2/1/2024.  MPIN # 007509811.   DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-11-17","","","2023-11-27","Rcvd Welcome letter. Provider effective 11/17/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",45047,"","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-03-03","","","2023-09-06","Provider has been confirmed. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-12-05","See Alliance WC payor line for details. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-12-19",""]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-05-25","","","2024-04-25","4/25/2024 provider enrolled as of 5/25/2023 via roster. FC"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-05-22","5/22/2023 Rcvd email from Caprock that May roster has been processed and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["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","USA PPO","Participating","Enrollment Complete",45047,"","","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 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"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"]
["Stacey Jo Guse, NP",1184108664,"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"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45139,"","","2023-07-31","07/31/2023 - Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO,  Medicare Advantage PPO and Health Select, effective 08/01/2023. PA"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-08-01","","","2023-07-31","07/31/2023 - Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO,  Medicare Advantage PPO and Health Select, effective 08/01/2023. PA"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-03-29","","","2024-05-29","incorrect username or password"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-07","","","2023-09-07","Rcvd welcome letter from Karina Garcia. Provider effective 09/07/2023. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2024-04-26","Sent email to Cassandra Dunagan- Smith requesting assistance with adding locations. PA"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-10-18","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W. Longview Ave and 6950 Eastridge. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-10-18","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W. Longview Ave and 6950 Eastridge. Jen Videan"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Pending Other Enrollment","2024-05-29","","","2024-06-03","Please see status updates under group record payor line. Jen Videan"]
["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","Participating","Enrollment Complete",45047,"","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 5/1/2023.  MPIN # 007509811  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2023-05-08","","","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 5/8/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2014-05-28","2761782","","2023-05-02","5.2.2023 Per confirm par status note - Per rep, provider is showing credentialed and in network under the TIN with an effective date 05/28/2014. Provider ID 2761782. Recredentialing date 10/13/2025. Service location is on file. Call ref#:AndrewJ04262023. DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Liberty Mutual","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2023-06-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to group delegated roster effective 6/1/2023.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-06-01","","","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 06/01/2023. Provider ID 1108138. Service location is on file. Call ref#:709557. - Danico Gabriel Melendres"]
["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","Aetna","Participating","Enrollment Complete","2023-05-01","","","2023-05-31","05.31.2023 S/W Ria of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 05/01/2023. Provider ID 4135209, Payer ID 60054 and Recredentialing date is 05/01/2026. Service location is on file. Call ref#:6149191218. - Danico Gabriel Melendres"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Payor Follow Up","2023-06-01","","","2023-12-27","12/27/2023 Priscilla Albertine at MQA sent follow-up email to Marcus Wester at Humana to try and get an updated and requested a roster.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","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","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","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-19",""]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-05-01","2W8694","","2024-04-16","Reconsideration request for the ICR was APPROVED and the effective date was backdated to 6/18/2023. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-09-16","000887435","","2023-10-05","10/5/2023 Rcvd copy of participating network list with effective dates for provider.  Provider is PAR with UHC effective 9/16/2023.  (see copy of report uploaded in attachments) DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","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","Cigna","Participating","Enrollment Complete","2023-11-15","2840278","","2023-11-30","Received enrollment confirmation. MS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",45108,"","","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"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",45047,"","","2023-08-16","Received email confirmation of approval for updated location. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",45139,"","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","4160673","","2023-08-04","8/4/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 4160673 DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45146,"","","2023-11-09","Received confirmation of Andrews Hwy location eff 11/6/2023. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-08","","","2023-10-26","Eastridge location approved eff 10/9/23. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-04-29","Q00537213","","2023-08-21","Confirmed enrollment. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2022-09-14","","","2023-08-31","8/31/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-05-16","5/16/2024 Provider not loaded in the system, resubmitted provider via delegated roster on 5/15/2024. FC"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-11-15","","","2023-11-27","Rcvd approval letter. Provider effective 11/15/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Application Submitted",45139,"","","2024-05-16","5/16/2024 Provider not loaded in the system, resubmitted provider via delegated roster on 5/15/2024. FC"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-18","App to update the group record has been submitted and is in processing. Once this has been approved, the providers record will automatically be updated at the same time. Nothing further is needed after that. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-08-01","","","2024-01-31","1/31/2024 Per Humana provider portal provider is PAR and linked to group TIN/locations effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal the provider is enrolled . MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",45156,"","","2023-09-21","Per Michelle Killough provider is effective 08/18/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",45323,"","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",45139,"","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",45139,"","","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, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete",45170,"3607159","","2024-04-25","4/25/2024 provider enrolled as of 9/1/2023 via roster. FC"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. Provider is not currently enrolled. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45440,"","","2024-05-28","05/28/2024 CAQH Reattested added one practice location wthompson"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45139,"","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",45139,"00008830908","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 8/1/2023.   MPIN# 00008830908.   DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Pending Other Enrollment",45440,"","","2024-06-10","Please see status updates under group record payor line. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-20","","","2023-10-19","10/19/23 Enrollment complete and participating with all products.  Effective date 10/20/23"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",45096,"3674906","","2023-11-07","11.07.2023 S/W Teresa of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 06/19/2023. Provider ID 3674906. Service location is on file. Call ref#:810269. - Danico Gabriel Melendres"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",45139,"","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-10-26","Rcvd welcome letter from Karina Garcia at Corvel. Provider is effective 10/26/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45045,"","","2023-08-22","Confirmed provider is linked to all group locations. MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal the provider is enrolled . MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-09","Per Benjamin Richbourg roster has been loaded and provider is effective 05/23/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-09","Per Benjamin Richbourg roster has been loaded and provider is effective 05/23/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-04",""]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",45139,"","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal the provider is enrolled . MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal the provider is enrolled . MS"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","4705 Briarwood Ave Midland, TX 79707, 210 West Longview Avenue Suite A Building A\nMidland, TX 79701 and 6950 Eastridge Rd\nOdessa, TX 79765 effective 09/01/2023. Jen Videan"]
["Andrea Sanders Sanchez, APRN-NP",1174237986,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal the provider is enrolled . MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-24","Credentialing Complete. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-12","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-01-24","Provider is loaded to Briarwood (eff 8/24/23)."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-05","Provider has been linked to Eastridge 10/9/23, Longview 8/24/23 and Andrews Hwy.  1/10/24  MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-05","Provider has been linked to Eastridge 10/9/23, Longview 8/24/23 and Andrews Hwy.  1/10/24  MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-12","9695700","","2023-10-24","10.24.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 06/12/2023. Next recredentialing date is 06/12/2026. PIN: 9695700. Servicing location is on file. Payer# 60054. Call ref# 6167813673. - Willie Ravas"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",45087,"Q00596481","DX4335","2023-11-08","Received enrollment confirmation. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Submitted","","","","2024-06-21","Location add pending under case#  09598462, per BCBSTX portal. PA."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45127,"","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 7/20/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location wthompson"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45441,"","","2024-05-29","05/29/2024 CAQH Reattested added one location wthompson"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-23",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",45157,"003289309","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/19/2023.  MPIN # 003289309.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-10","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/10/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-10","","","2023-10-10","10/10/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/10/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-18","Group enrollment has been submitted. If the payor wants to contract, they will reach back out and request a roster. There is no follow up needed. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via the Coventry portal. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 08/25/2023.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-06-12","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2024-05-14","Pending group app approval. This was submitted 5/14/24. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-06-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-06-01","2243378","","2023-11-20","11/20/2023 S/W Sam of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 06/01/2023. Provider ID 2243378. Physical locations are on file. Call ref#:773026. - DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-06-12","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-10-02","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-08-25","","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Provider Load","Provider Load","2024-05-29","","","2024-05-29","new location"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45281,"","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-24","Per Benjamin Richbourg, roster has been successfully loaded. They do not have effective dates for individual providers. The only effective date is the one on the contract. For this contract effective date is 05/23/2023. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-08-19","003289309","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/19/2023.  MPIN # 003289309.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-06-12","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 6/12/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-14","1073983193","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Participating","Enrollment Complete","2023-05-29","1073983193","","2024-01-16","Approval letter rcvd. Dana Bell is effective at 5424 19th St Ste 300 Lubbock TX effective 05/29/2023. Jen Videan"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2023-09-01","1073983193","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/ all locations effective 9/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","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","2023-05-29","Q00516460","CF8499","2023-07-19","7/19/2023 Rcvd RR Medicare approval letter.   PTAN # Q00516460 - effective 5/29/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","Participating","Enrollment Complete","2023-08-01","19103471","","2024-01-09","1/9/2024 Per Amerigroup web portal provider is PAR and linked to Lubbock location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","Participating","Payor Follow Up","2023-08-01","19103471","","2024-01-16","1/16/2024 Sent follow-up email to Cassandra Dunagon-Smith at Amerigroup to check status of August roster.  Have not received responses from previous requests.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete","2023-05-29","853821","","2024-02-12","Received completion notice. MS"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","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","Wellcare","Participating","Enrollment Complete","2023-09-01","1073983193","","2023-09-13","9/13/2023 Rcvd email from Superior confirming that the August delegated roster provider load has been completed providers are PAR and loaded under TIN/ all locations effective 9/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","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"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","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","IMS","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","IMS","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-08-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment updates. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Humana","Participating","Enrollment Complete","2024-01-26","","","2024-05-22","5/22/2024 Provider participating as of 1/26/2024 listed as PCP spoke to Jen R. call Ref#2000387504047. FC"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-01","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Coventry Workers Comp","Participating","Enrollment Complete","2023-06-11","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","United Health Care","Participating","Enrollment Complete","2023-08-01","00005273773","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 8/1/2023.   MPIN# 00005273773.   DCannon"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2023-09-08","002471104","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2023-08-01","2X6561","","2023-08-16","Received approval letter. MS"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","","","2023-09-05","Received confirmation letter. MS"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-06-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 6/1/2023.  DCannon"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-01","","","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"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete",45188,"","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",45202,"","","2023-10-09","10/9/2023 Per email received from Scott & White provider is PAR and linked to group effective 10/3/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2023-09-19","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2023-09-25","","","2023-11-03","Providers specialty has been approved. MS"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-24","Pending Aetna approval. MS"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-09-25","Q00593564","CE1588","2023-11-06","Received confirmation eff 9/25/2023. MS"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete",45231,"","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete",45177,"","","2023-12-28","12/28/2023 Per Humana online web portal provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-07-10","","","2023-11-20","11/20/2023  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to locations/TIN effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45271,"","","2023-12-18","Welcome letter rcvd. Provider effective 12/11/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45271,"","","2023-12-18","Welcome letter rcvd. Provider effective 12/11/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-07-10","008760942","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 7/10/2023.  MPIN # 008760942.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45117,"","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-07-20","Q00602406","DX4335","2023-11-16","notes are on other payor lines. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-16","08/16/2023. We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45183,"","","2023-08-31","8/31/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45183,"","","2023-08-31","8/31/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-07-10","","","2023-09-12","9/12/2023 Per email received from Caprock provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-10-06","4705 Briarwood Ave, 210 West Longview Ave Ste A Bldg A and 6950 Eastridge  are effective 09/01/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete",45107,"","","2024-04-25","4/25/2024 provider enrolled as of 6/30/2023 via roster. FC"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-07-10","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-07-10","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-07-10","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-08-25","","","2023-09-28","Per Michelle Killough provider is effective 08/25/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",45117,"","","2024-01-31","1/31/2024 Per Humana provider portal provider is PAR and linked to group TIN/locations effective 7/10/2023.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-10","","","2024-01-24","Credentialing Complete. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","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, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-29","008760942","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 9/29/2023.  MPIN # 008760942.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-29","008760942","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 9/29/2023.  MPIN # 008760942.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2023-08-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/locations, eff.  08/01/2023. PA."]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-03-08","15954818","","2024-05-29","incorrect username and password"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-16",""]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2024-04-26","Sent email to Cassandra Dunagan- Smith requesting assistance with adding locations. PA"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-11-05","Revalidation completed. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-10-26","Eastridge location confirmed effective 10/9/2023. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-16","","","2023-10-26","Eastridge location confirmed effective 10/9/2023. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-19","","","2023-10-19","10/19/2023 Enrollment had to be resubmitted, new effective date for all products is 10/19/23. NGaneshraj"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-07-20","6C3759","","2023-11-01","Please see other payor line for enrollments notes. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Taylor Brown. Effective 12/05/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-12-19","Per providerdata@careworks.com 6301 Andrews Hwy has been loaded for Taylor Brown. Effective 12/05/2023. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","","","","2023-10-23","Rcvd acceptance letter from cynthia.clancy@sedgwick.com, provider effective 10/18/2023 at 4705 Briarwood, 210 W Longview Ave and 6950 Eastridge. Jen Videan"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Facility Enrollment","","","","2023-09-13","Rep confirmed there is an ancillary contract in place. Ancillary provider are not required to be enrolled individually. Claims are bill through the group. MS"]
["Taylor Brown, APRN-FNP-BC",1104519057,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-07-10","8683782","","2023-09-19","09.19.2023 S/W IceB of Aetna @ 1-800-353-1232. Per rep, provider is in network with Aetna for the state of TX and participating under the group and TIN# effective 07/10/2023. PIN: 8683782. Physical locations are on file. No next recredentialing date available. Payer# 60054. Call ref# 6163752278. - Willie Ravas"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete",45160,"008866025","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-06-28","6/28/2023- per notification form, provider will maintain own CAQH - kavello"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete",45200,"","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2023-10-06","","","2023-10-09","Received confirmation email. Attached. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2023-08-22","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-10-20","Provider is linked to the Rosalind location. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-14","","","2023-09-26","Provider has been loaded to the Andrews Hwy location effective 9/14/23. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2023-08-22","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-08-22","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2023-08-22"," 8574198","","2023-10-19","10.16.2023 S/W Anthony of Aetna @ 1-800-353-1232. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 08/22/2023. Provider ID 8574198. Service location is on file. Call ref#:6166954339.-Danico Gabriel Melendres"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2023-08-22","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2023-08-22","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2023-08-22","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 8/22/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-24",""]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2024-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-09-24","Q00602400","","2023-11-16","Received confirmation. MS"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","Participating","Enrollment Complete","2024-01-01","","","2024-01-26","1/25/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 1/1/2024"]
["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","Caprock (CapStar)","Participating","Enrollment Complete",45177,"","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","2024-05-30","","","2024-05-30","Please see status updates under Alliance WC payor line. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-08-01","","","2023-10-11","Received confirmation of enrollment attached. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45214,"","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 10/15/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45161,"","","2023-09-26","Confirmed Briarwood and Longview locations effective 8/23/23. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-09-26","Confirmed Briarwood and Longview locations effective 8/23/23. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-10-26","Eastridge location completed effective 10/9/2023. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-08-23","","","2023-11-05","Revalidation completed. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45161,"","","2023-11-05","Revalidation completed. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-08-01","2Y3057","","2023-08-29","Received completed enrollment. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-08","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45177,"","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",45177,"008870743","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete",45200,"","","2023-11-03","11/3/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45275,"","","2023-12-19","Received email with welcome letter from Karina Garcia effective 12/15/2023. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45275,"","","2023-12-19","Received email with welcome letter from Karina Garcia effective 12/15/2023. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","","","2023-09-27","9/27/2023 Rcvd email confirmation from Caprock that the September roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2023-11-20","participating, please see Alliance WC for updated notes. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-09-01","","","2024-04-25","4/25/2024 provider enrolled as of 9/1/2023 via roster. FC"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-09-08","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-05","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","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, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2023-09-08","3746844","","2023-11-20","11/20/2023 S/W James of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 9/8/2023. Provider ID 3746844. Physical locations are on file. Call ref#:773110. - DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-09-08","","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-12","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-12","Provider is active at 6950 Eastridge Rd, 210 West Longview Ave and 4705 Briarwood Ave. Effective 11/01/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-09-08","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Panel Closed","Panel Closed","","","","2023-08-15","We appreciate your interest in joining the Coventry Network.  At this time, our panels are closed, and we are not accepting new applications.  Please check back routinely to stay apprised of our panel status. We will update this site when we are open for new applicants. Gallagher, Hartford, Liberty Mutual, Travelers and Zurich fall under Coventry. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-09-08","","","2023-12-28","12/28/2023 Per Humana online web portal provider is PAR and linked to group TIN/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-08","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/8/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-09-08","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-11",""]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-08-11",""]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",45191,"","","2023-09-27","Rcvd welcome letter from Barry Harris at barry.harris@pswca.org. Provider effective 09/22/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-30","","","2024-05-30","05/30/2024 CAQH Reattested added one location wthompson"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-20","WTUC has an active Ancillary Contract in effect, which means any midlevel will not require credentialing and all services will be billed under the group contract. MS"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45208,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that October delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 10/9/2023.  DCannon"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-05-31","","","2024-05-31","05/31/2024 CAQH Reattested updated and uploaded board wthompson"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-05-31","","","2024-05-31","05/31/2024 CAQH Reattested all location current and all expirables up to date wthompson"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-04","Panel is closed to this specialty until further notice. MS"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-02","","","2023-11-03","11/3/2023 Per email received from Scott & White provider is PAR and linked to group effective 11/2/2023.  DCannon"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete",45236,"","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Cigna","Participating","Enrollment Complete",45415,"5056023","","2024-05-06","Received confirmation of enrollment. MS"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Participating","Enrollment Complete","2023-09-25","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare for the Briarwood location. MS"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2023-09-08","1083394977","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Superior","Participating","Enrollment Complete",45200,"1083394977","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2024-06-04","16016463","","2024-06-04","06/04/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2023-09-25","1083394977","","2024-02-28","Providers revalidation has been completed. eff 9/25/23 MS"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-11-01","9905419","","2023-12-12","Received confirmation email. MS"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-10-16","","","2023-10-27","Confirmed enrollment effective 10.16.2023. MS"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-04","Pending Aetna approval. MS"]
["Billy S Gao, MD",1699092304,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Resubmitted","","","","2024-05-01","Rep researched the application and asked a letter of request be faxed to 859-455-8650 to include all the providers information, requesting to be linked to this TIN. After 2 days, call and request the DCN # for tracking purposes. MS  REF 6190998713"]
["Billy S Gao, MD",1699092304,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2023-12-06","1912452053","","2023-12-27","12/27/2023 Rcvd TMHP Approval letter.  Provider is PAR effective 12/6/2023.  TPI # 1912452053.  DCannon"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2023-12-06","6700596","","2024-02-14","Received welcome email. MS"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","","","","2023-09-18","9/18/13-Per notification form - provider will maintain - kavello"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete",45236,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete",45236,"","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2023-09-25","","","2023-10-27","Provider linked to Rosalind and Andrews Hwy location eff 9/28/2023. MS"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete",45236,"006258398","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/6/2023. \nMPIN # 006258398.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-20","Per the website, the panel is closed to new providers at this time. MS"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Thru Other Payor","Pending Other Enrollment","","","","2024-01-30","1/30/2024 Per UHC portal provider load in Wellmed is still pending.  Will check back in a few days.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete",45236,"","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2023-11-06","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023, linked to TIN and the following locations 4214 Andrews HWY, 801 E Florida Ave, and 400 Rosalind Redfern.  PA"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete",45236,"","","2024-05-20","5/20/2024 Provider participating as of 11/6/2023 via April roster. FC"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-10-01","Q00656144","","2024-02-05","Confirmed provider is enrolled eff 10/1/2023. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45236,"","","2024-04-25","Per Amerigroup roster, provider is PAR, eff. 11/06/2023, locations linked: 210 W Longview, 6301 Andrews, 6950 Eastridge Rd, and 4705 Briarwood Ave. PA."]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2023-12-15","","","2024-01-05","Welcome ltr rcvd. Provider effective 12/15/2023. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-10-01","6C9661","423838","2023-11-08","Received approval letter eff 10/1/2023 MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-16","Confirmed provider is linked to all Briarwood and Longview locations effective 10/9/23. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-18","Group is not Tricare Credentialed and the payor is not accepting new enrollments at this time. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete",45275,"","","2024-01-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from Scott & White November roster has been completed.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","No Value Specified","2023-12-01","","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 12/01/2023, and linked to locations.PA"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","","","","2024-03-06","Provider is linked. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-09","Payor has closed the panel for new providers. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-09","Payor has closed the panel for new providers. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-10-01","","","2024-01-30","Confirmed via Coventry portal provider is enrolled. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-21","","","2023-12-05","12/05/2023: Received email from Connie Traylor, stating \"Kristen Schlemeyer PA, is effective in Blue Choice PPO, Blue Essentials HMO, Health Select, Blue Advantage HMO, and Medicare Advantage PPO networks 11/21/2023. TIN ending in 5832.\" Copy of email uploaded. - PA"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-11-21","","","2023-12-05","12/05/2023: Received email from Connie Traylor, stating \"Kristen Schlemeyer PA, is effective in Blue Choice PPO, Blue Essentials HMO, Health Select, Blue Advantage HMO, and Medicare Advantage PPO networks 11/21/2023. TIN ending in 5832.\" Copy of email uploaded. - PA"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-11-06","00390311","","2024-01-29","1/29/2024 Per UHC provider portal probider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00390311.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal provider is enrolled. MS"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location wthompson"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-02-01","008766524","","2024-01-30","1/30/2024 Rcvd email confirmation from UHC that January delegated roster has been completed.  Provider is PAR and linked to group/location effective 2/1/2024.  MPIN # 008766524.   DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Provider Load","Provider Load","2024-05-29","","","2024-05-29","new location"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2023-12-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 12/01/2023. PA."]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45236,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete",45261,"","","2023-12-04","Enrollment complete for 4705 Briarwood, 6950 Eastridge and 210 W Longview. Effective 12/01/2023. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45334,"","","2024-02-13","Welcome ltr rcvd. Provider effective 02/12/2024. Jen Videan"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45236,"","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Kristen Grace Schlemeyer, PA",1790315737,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45343,"","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2024-04-01","6K7156","0008AH","2024-02-27","Received welcome letter. MS"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2024-02-05","","","2024-04-02","3/20/2024 Received confirmation from Jessica Bess via email, provider effective with Multiplan 2/5/2024. FC."]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/5/2024 received via email. FC"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-01-03","Group holds am Ancillary contract which will bill for the midlevel services under the group. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-10-01","Q00615975","","2023-12-07","Received approval letter. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-11-06","","","2024-04-25","Per Amerigroup roster, provider is PAR, eff. 11/06/2023, locations linked: 210 W Longview, 6301 Andrews, 6950 Eastridge Rd, and 4705 Briarwood Ave. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2024-02-28","Per brandhi_wilson-woods@corvel.com location has been added for provider with effective date 7/2020. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",45236,"","","2023-12-21","12/21/2023 Per Humana online directory provider is PAR and linked to group TIN and  all locations effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete",45200,"2231549","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45261,"","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-11-06","003261515","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 003261515.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-11-06","003261515","","2023-12-27","12/27/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 11/6/2023.  MPIN # 003261515.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 11/06/2023 and linked to locations:  4705 Briarwood, 6950 Eastridge  Rd, 6301 Andrews Hwy, and 210 Longview. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-06","","","2023-11-30","11/30/2023 Per email received from Caprock, November Delegated roster has been completed.  Provider is PAR and linked to group TIN effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-16","Payor has closed the enrollment panel until further notice. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/19/2024 Pending Multiplan enrollment.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45225,"","","2023-10-26","Provider is loaded to the Eastridge location eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2024-02-07","Confirmed provider is linked to Main St. location eff 1/19/2024. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45225,"","","2024-02-07","Confirmed provider is linked to Main St. location eff 1/19/2024. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45441,"","","2024-05-29","05/29/2024 CAQH Reattested added one practice location wthompson"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-11-06","00390310977","","2024-01-29","1/29/2024 Per UHC provider portal probider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00390310977.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45236,"","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45236,"","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2023-12-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  12/01/2023. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",45275,"","","2024-01-05","Welcome letter rcvd. Provider effective 12/15/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",45261,"","","2024-05-17","Received email confirmation from (FirstHealthCustomerServiceMailbox@AETNA.com) provider is PAR, eff. 12/01/2023 and linked to all locations. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",45236,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",45236,"","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 11/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-25","","","2023-10-24","Received confirmation provider is enrolled and participating with the following networks, eff. 10/25/2023:\nBAV - Blue Advantage HMO\t,\nHME - Health Select,\nBCA - BlueChoice PPO,\nHMO - Blue Essentials, and\nPMC - Medicare Advantage PPO\n- PA"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete",45275,"","","2024-01-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45334,"","","2024-02-13","Rcvd welcome letter. Provider effective 02/12/2024. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45334,"","","2024-02-13","Rcvd welcome letter. Provider effective 02/12/2024. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-03-20","","","2024-03-21","Approval ltr rcvd. Provider effective 03/20/2024. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45200,"6C9153","","2023-11-08","Received welcome letter. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-11-06","","","2023-12-28","12/28/2023 S/W Paul of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group TIN and location effective 11/06/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-18","Payor is not accepting new enrollments until further notice. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-10-18","Payor is not accepting new enrollments until further notice. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",45310,"","","2024-01-29","Alliance WC approval letter rcvd. Provider effective 01/19/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-04-30","Sent email to firsthealthcustomerservicemailbox@aetna.com for enrollment status. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-10-27","Group has an ancillary contract in place, therefore, all services for midlevels will be billed under the group. no credentialing is required. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",45264,"","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45264,"","","2024-01-11","1/11/2024 Per email rcvd from Karen Avalos at Galaxy December roster is complete.  Provider is PAR and linked to group TIN/locations effective 12/4/2023.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-01-12","","","2024-05-09","Per Marina Martinez of USA MCO, provider is par, eff. 01/12/2024, and linked to TIN/locations. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45252,"","","2023-11-27","11/27/23: Received confirmation from BCBSTX per email, provider enrolled with the following networks, eff. 11/22/23:\nBAV - Blue Advantage HMO\nPMC - Medicare Advantage PPO\nBCA - BlueChoice PPO\t\nHME - Health Select\t\nHMO - Blue Essentials"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-21","","","2024-05-28","Spoke to Irish call ref#6193526649 all four location participating as of 5/21/2024. FC"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Superior","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","","","","2024-06-24","Received email confirmation from Karen Avalos, location add complete, eff. 02/01/2024."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-02-12","","","2024-02-13","Welcome ltr rcvd. Provider effective 02/12/2024. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete",45200,"","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment status. Provider is not currently listed. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete",45264,"","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 12/4/2023.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending Multiplan enrollment.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 12/04/2023 and linked to locations:  4705 Briarwood, 6950 Eastridge  Rd, 6301 Andrews Hwy, and 210 Longview. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-10-26","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-12-04","","","2024-04-25","Per Amerigroup roster, provider is PAR, eff. 12/04/2023, locations linked: 210 W Longview, 6301 Andrews, 6950 Eastridge Rd, and 4705 Briarwood Ave. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45419,"","","2024-04-30","Received confirmation the group enrollment record has been updated to show the Main St. location added eff 5/7/2024. The providers record is auto-updated to show the info as well. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-30","Confirmed via Coventry portal, provider is loaded. MS"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2023-11-06","Per providerrelations@primehealthservices.com, provider has been added. effective date 05/23/2023. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-01-19","","","2024-01-29","Please see status updates under Alliance WC payor line. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Superior","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-04","Enrollment complete for 4705 Briarwood, 6950 Eastridge and 210 W Longview. Effective 12/01/2023. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-11","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's record. Jen Videan"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","15380393","","2024-05-28","05/28/2024 CAQH Reattested added one location wthompson"]
["Alma Martinez, APRN-FNP-BC",1376149153,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Bailey Bergman, PA",1447851639,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","No Value Specified","Enrollment Complete","2024-04-01","","","2024-06-04","Received email confirmation from shpdelegation@superiorhealthplan.com provider is PAR, linked to TIN and locations, eff. 04/01/2024. PA"]
["Bailey Bergman, PA",1447851639,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2024-03-11","","","2024-05-24","Par through Multiplan enrollment, eff. 03/11/2024. PA"]
["Bailey Bergman, PA",1447851639,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete",45447,"","","2024-06-04","Received email confirmation from shpdelegation@superiorhealthplan.com provider is PAR, linked to TIN and locations, eff. 04/01/2024. PA"]
["Bailey Bergman, PA",1447851639,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","In Process","Thru Other Payor",45331,"","","2024-03-19","Pending UHC enrollment. PA"]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",45273,"Q00683122","CE1588","2024-03-07","Received confirmation of enrollment. MS"]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-24","Pending Aetna approval. MS"]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-12","","","2024-01-25","Due to provider's specialty, credentialing isn't required. Provider is in network with Tricare. MS"]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2024-03-15","","","2024-05-23","Received email confirmation (from hpregion3@bswhealth.org) provider is PAR, eff. 3/15/2024, and linked to TIN/location. PA."]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-15","","","2024-04-29","Provider's recert has been approved eff 1/15/2024. MS"]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","In Process","Application Submitted","","","","2024-02-16","2/16/2024 - submitted application via delegated monthly roster on 02/15/2024. PA."]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Participating","Enrollment Complete","2024-02-26","6568171","","2024-03-22","03.22.2024 DM: Called Cigna Healthspring @ 1-800-997-1654 to obtain PNP/FU status for the provider and spoke to Crystal. Per rep, provider is showing participating and link under the Group and TIN witn an Effective date 02/26/2024. Provider ID 6568171, Payer ID 62308 and No Recredentialing date. Service location is on file. Call ref#:CrystalB03222024."]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Galaxy Health","Participating","Enrollment Complete","2024-02-05","","","2024-03-21","3/21/2024 - received email confirmation from Karen Avalos (kavalos@ghn-mci.com) Feb. roster completed. Provider is now PAR, eff. 02/05/2024. PA."]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (hpdelegation@bswhealth.org) requesting update on enrollment status. PA."]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-27","Check Coventry portal for enrollment status. MS"]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","","Medicare","Participating","Enrollment Complete",45502,"","","2024-06-12","Received welcome letter. MS"]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-04-09","Pending Medicare approval. MS"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","","Cigna","In Process","Payor Receipt Validated","","","","2024-06-21","Application has been received and is processing. MS Ref #13741394. MS"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","","Tricare Prime","In Process","Payor Receipt Validated","","","","2024-05-21",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","2024-05-29","","","2024-06-20","Submitted location add via delegated roster on 6/15/2024. PA."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-21","1063119162","","2024-05-22","Approval ltr rcvd. Provider effective 05/21/2024. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-21","1063119162","","2024-05-22","Approval ltr rcvd. Provider effective 05/21/2024. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-03-22","","","2024-04-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-04-01","","","2024-05-10","Received email confirmation from shpdelegation@superiorhealthplan.com, provider is par and linked to TIN/locations, eff. 04/01/2024. PA"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-03-10","","","2024-05-20","5/20/2024 Provider participating with all locations as of 3/11/2024 via April roster. FC"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-05-01","Payor has requested not to send follow up requests as they will review the need for at the group level first. If they want to contract, they will reach out and request a roster of all providers under TIN. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-02-12","Q00683123","DX4335","2024-03-07","Confirmed provider is enrolled. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted",45329,"","","2024-03-18","3/18/2024- Submitted application via delegated monthly roster on 3/15/2024. FC."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted",45329,"","","2024-03-18","3/18/2024- Submitted application via delegated monthly roster on 3/15/2024. FC."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-18","App to update the group record has been submitted and is in processing. Once this has been approved, the providers record will automatically be updated at the same time. Nothing further is needed after that. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-02-07","","","2024-02-26","02/26/2024 - received email confirmation provider is par, eff. 02/27/2024, and added to the following networks: BAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-03-11","","","2024-05-29","Provider participating as of 3/11/2024 received via email from Kodi Kox. FC"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-02-08","Location is not certified, so panel is closed to new providers. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-02-08","Location is not certified, so panel is closed to new providers. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-05","Provider has been linked to the Longview location eff 2/28/24. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-03-13","Provider is linked to Briarwood, Main St., Eastridge, and Andrews Hwy locations 3/5/24."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-03-11","","","2024-05-29","Provider participating as of 3/11/2024 received via email from Kodi Kox. FC"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","2024-02-07","","","2024-06-21","Sent email requesting group roster from UHC. PA.Sent email requesting group roster from UHC. PA."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-02-07","","","2024-03-12","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-02-07","","","2024-03-12","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","2024-02-07","","","2024-03-18","3/18/2024- Submitted application via delegated monthly roster on 3/15/2024. FC."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","2024-02-07","","","2024-06-21","Sent email to payor requesting enrollment status. PA."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up","2024-02-07","","","2024-06-21","Sent email to payor requesting enrollment status. PA."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","2024-02-07","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-05-21","1063119162","","2024-05-23","Approval ltr rcvd. Effective 05/21/2024. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45362,"","","2024-04-16","Received email from Karen Avalos confirming roster completed; provider is PAR, eff. 03/11/2024. PA."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-06-20","Submitted location add via delegated roster on 6/15/2024. PA."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Boon Chapman","Pending Other Enrollment","Thru Other Payor","2024-02-07","","","2024-04-30","4/30/2024 pending Multiplan enrollment. FC"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-02-12","6K9986","","2024-02-29","Received welcome letter. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-02-12","6K9986","","2024-02-29","Received welcome letter. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-04-01","","","2024-04-08","Rcvd approval ltr. Provider effective 04/01/2024. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",45373,"","","2024-04-01","Approval ltr rcvd. Provider is effective 03/22/2024. Jen Videan"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-03-11","","","2024-05-20","5/20/2024 Spoke to Schika call ref#6192842761, all WTUC locations participating as of 3/11/2024. FC"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Provider Load","Provider Load","2024-02-07","","","2024-02-07",""]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-02-01","","","2024-05-10","Received email confirmation from shpdelegation@superiorhealthplan.com, provider is par and linked to TIN/location, eff. 02/01/2024. PA"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Payor Follow Up","2024-02-07","","","2024-05-29","Sent email to Mary Rodriguez (mary.rodriguez@90degreebenefits.com) requesting enrollment status. FC"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Provider Load","Provider Load","2024-05-29","","","2024-05-29","new location"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-02-12","TIN has a ancillary contract in place so midlevels do not require credentialing. Services are billed under the group contract, not the ind. provider. MS"]
["Katherine Ann Wright, PA",1063119162,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","2024-02-07","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-04-10","Eastridge, Andrews, Main St, and Longview location are all effective 3/13/2024. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Briarwood location eff 3/7/2024. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-03-07","","","2024-03-13","Provider is linked to Briarwood location eff 3/7/2024. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-05-01","1184490161","","2024-05-09","Approval ltr rcvd. Effective 05/01/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Submitted","","","","2024-06-21","Location add pending under case#  09598462, per BCBSTX portal. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45358,"","","2024-04-15","4/15/2024- received email confirmation provider is par, eff.  04/16/2024, and participating with the following networks: PMC - Medicare Advantage PPO\nBCA - BlueChoice PPO\nBAV - Blue Advantage HMO\nHMO - Blue Essentials\nHME - Health Select. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Provider Load","Action Needed","2024-03-07","","","2024-03-07",""]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Payor Follow Up",45358,"","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-18","App to update the group record has been submitted and is in processing. Once this has been approved, the providers record will automatically be updated at the same time. Nothing further is needed after that. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","2024-03-07","","","2024-04-15","4/15/2024 Delegated roster submitted.  FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Payor Follow Up",45358,"","","2024-06-21","Sent email to UHC requesting group roster. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45357,"","","2024-03-25","Received approval. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","2024-03-07","","","2024-05-31","Sent email to payor (kavalos@ghn-mci.com and mmonroe@ghn-mci.com) requesting update on enrollment status. PA"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added on practice location wthompson"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-28","","","2024-05-28","05/28/2024 CAQH Reattested added on practice location wthompson"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-03-07","","","2024-03-12","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2024-05-02","Payor has requested not to send follow up requests as they will review the need for at the group level first. If they want to contract, they will reach out and request a roster of all providers under TIN. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Payor Follow Up","","","","2024-05-02","Payor has requested not to send follow up requests as they will review the need for at the group level first. If they want to contract, they will reach out and request a roster of all providers under TIN. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-04-10","WesTex Urgent Care PLLC  is currently contracted with Cigna via an Ancillary contract. This provider does not require credentialing or contracting and should bill all services rendered under the Ancillary contract."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Payor Follow Up",45358,"","","2024-05-29","Sent email to Mary Rodriguez (mary.rodriguez@90degreebenefits.com) requesting enrollment status. FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",45387,"","","2024-05-20","5/20/2024- Spoke to Max C call ref# 6192813282 provider participating with all 5 locations effective as of 4/5/2024, provider listed as a SPEC. FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up",45358,"","","2024-05-10","Enrollment submitted 03/11/2024. Allow 90 days for processing.  Still within timeframe...allow more time. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","2024-03-07","","","2024-04-15","4/15/2024 Delegated roster submitted.  FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","2024-03-07","","","2024-04-15","4/15/2024 Delegated roster submitted.  FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-04-05","","","2024-05-29","Provider participating as of 4/5/2024 received via email from Kodi Kox. FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","2024-05-28","","","2024-06-20","Submitted location add via delegated roster on 6/15/2024. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Provider Load","Provider Load","2024-03-07","","","2024-03-07",""]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-05-05","","","2024-05-09","Received confirmation from HPDelegation provider is PAR & locations linked, eff. 05/05/2024."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-04-12","","","2024-04-22","Approval ltr rcvd. Provider effective 04/12/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-03-06","Q00724731","","2024-04-25","Received confirmation of enrollment. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-03-06","Q00724731","","2024-04-25","Received confirmation of enrollment. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete",45394,"","","2024-04-22","Please see status updates under Alliance WC payor line. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-04-15","4/15/2024 Delegated roster submitted.  FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45413,"","","2024-05-10","Received email confirmation from shpdelegation@superiorhealthplan.com, provider is par and linked to TIN/location, eff. 05/01/2024. PA"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45413,"","","2024-05-10","Received email confirmation from shpdelegation@superiorhealthplan.com, provider is par and linked to TIN/location, eff. 05/01/2024. PA"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","2024-03-07","","","2024-05-21","Emailed  Brandhi_Wilson-Woods@Corvel.com for status. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","2024-03-07","","","2024-05-21","Emailed  Brandhi_Wilson-Woods@Corvel.com for status. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-03-07","This TIN is not Tricare Credentialed, and the panel is closed to incoming requests. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-05-01","","","2024-05-10","Received email confirmation from shpdelegation@superiorhealthplan.com, provider is par and linked to TIN/location, eff. 05/01/2024. PA"]
["Robert John Cornell, MD",1457331803,"75-1997880","TX","PE - Andrews County Hospital District","Cigna","Participating","Enrollment Complete",45383,"0224388","","2024-04-24","Received confirmation email. MS"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","","Texas Mutual","Enrollment on Hold","Enrollment on Hold","2024-05-20","","","2024-05-22","Effective date is 8/11/24. Enrollment on hold pending TX DEA and COI. Jen Videan"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","In Process","Payor Follow Up",45432,"","","2024-05-29","Per brandhi_wilson-woods@corvel.com provider has been sent to be cred/added. Allow up to 180 days. Jen Videan"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Provider Load","CAQH Reattested",45453,"","","2024-06-10","06/10/2024 CAQH Reattested updated and uploaded DEA wthompson"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","","TriCare Standard","In Process","Application Submitted","","","","2024-05-22","Certification application submitted via secure portal. MS"]
["Laura V Salcido, PA",1669755906,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-06-17","Pending UHC enrollment. PA."]
["Laura V Salcido, PA",1669755906,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-05-22","Application submitted via online site. MS"]
["Laura V Salcido, PA",1669755906,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-05-06","Pending Medicare approval. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-10","1548026099","","2024-05-17","Welcome ltr rcvd. Effective 05/10/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-04-30","","","2024-04-30","Received email confirmation provider is PAR, eff. 04/30/2024, participating in the following networks: BAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-03-15","6P6674","","2024-04-30","Received welcome letter eff 3/15/24. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-03-15","6P6674","","2024-04-30","Received welcome letter eff 3/15/24. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2026-06-01","1548026099","","2024-06-11","Approval ltr rcvd. Effective 06/01/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2026-06-01","1548026099","","2024-06-11","Approval ltr rcvd. Effective 06/01/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-05-15","Pending enrollment through UHC. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete",45418,"","","2024-05-27","Received email confirmation from Christy Henson (CHenson@pphealthplan.com) provider is PAR and linked to TIN/locations, eff, 5/06/2024. PA"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete",45418,"","","2024-05-27","Received email confirmation from Christy Henson (CHenson@pphealthplan.com) provider is PAR and linked to TIN/locations, eff, 5/06/2024. PA"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-18","Group is not Tricare Credentialed and the payor is not accepting new enrollments at this time. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","","","","2024-05-14","Provider enrolled at the briarwood location eff 4/30/2024. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-05-14","Application submitted to add Main St, Andrews Hwy., Eastridge, and Longview locations. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-06-03","This is a facility enrollment. No credentialing is required for individual providers. Provider will bill services through the group contract. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-05-01","Payor has requested not to send follow up requests as they will review the need for at the group level first. If they want to contract, they will reach out and request a roster of all providers under TIN. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-04-10","WesTex Urgent Care PLLC  is currently contracted with Cigna via an Ancillary contract. This provider does not require credentialing or contracting and should bill all services rendered under the Ancillary contract."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-06","","","2024-06-19","6/19/2024 Spoke to Ethan S. call ref#6195709020 provider participating as of 5/6/2024. FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-06","","","2024-06-19","6/19/2024 Spoke to Ethan S. call ref#6195709020 provider participating as of 5/6/2024. FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","2024-04-08","","","2024-05-14","Pending group enrollment. Request letter submitted 5/14/2024. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2024-04-08","","","2024-04-09","Location is not Tricare Credentialed, and the panel is closed for new providers. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","2024-04-08","","","2024-04-09","Location is not Tricare Credentialed, and the panel is closed for new providers. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Active","Pending Info/Document","2024-04-12","","","2024-05-29","incorrect username and password"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Thru Other Payor","Enrollment Complete","2024-06-01","","","2024-06-04","Per SHP validation report, provider is PAR, linked to TIN and locations, eff. 06/01/2024. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","2024-04-08","","","2024-05-21","Allow 60-90 days for credentialing. Application submitted 04/10/2024. Allow more time. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","2024-04-08","","","2024-05-21","Allow 60-90 days for credentialing. Application submitted 04/10/2024. Allow more time. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-04-22","","","2024-04-24","Received email confirmation provider is PAR, eff. 04/22/2024, participating with the following networks: BAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1093796435","","2024-05-06","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-04-12","Locations are not Tricare Credentialed and they are not accepting new providers. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-04-12","Locations are not Tricare Credentialed and they are not accepting new providers. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45394,"","","2024-04-28","Provider is linked to all 5 locations eff 4/12/24. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-06-01","1093796435","","2024-06-11","Approval ltr rcvd. Effective 06/01/2024. Jen Videan"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-10","1093796435","","2024-05-17","Please see status updates under Alliance WC payor line. Jen Videan"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-10","1093796435","","2024-05-17","Please see status updates under Alliance WC payor line. Jen Videan"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45444,"","","2024-06-04","Per SHP validation report, provider is PAR, linked to TIN and locations, eff. 06/01/2024. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-04-12","Group holds an ancillary contract where services are billed through the group, not the individual. Credentialing is not required. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-04-12","Group holds an ancillary contract where services are billed through the group, not the individual. Credentialing is not required. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",45418,"","","2024-06-19","6/19/2024 Spoke to Ethan S. call ref#6195709020 provider participating as of 5/6/2024. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete",45418,"","","2024-05-27","Received email confirmation from Christy Henson (CHenson@pphealthplan.com) provider is PAR and linked to TIN/locations, eff, 5/06/2024. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete",45418,"","","2024-05-27","Received email confirmation from Christy Henson (CHenson@pphealthplan.com) provider is PAR and linked to TIN/locations, eff, 5/06/2024. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-18","Group enrollment has been submitted. If the payor wants to contract, they will reach back out and request a roster. There is no follow up needed. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-04-24","Received email from payor requesting to hold on any provider submissions until the group enrollment has been decided. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-04-24","Received email from payor requesting to hold on any provider submissions until the group enrollment has been decided. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-05-15","Submitted enrollment application via delegated roster. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-05-15","Pending enrollment through UHC. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-05-15","Pending enrollment through UHC. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2019-03-13","","","2024-04-24","Received enrollment confirmation eff 3/13/24. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-03-13","Q00738696","DX4335","2024-05-14","Received approval. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location wthompson"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location wthompson"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-10","1093796435","","2024-05-17","Welcome ltr rcvd. Effective 05/10/2024. Jen Videan"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-18","Group app to add this location has been submitted. Once that has been approved, a link app will need to be submitted to add the provider. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-05-10","Q00744975","DX4335","2024-05-22","Received confirmation. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-05-15","","","2024-05-15","Received email confirmation provider is PAR, eff. 05/15/2024, TIN and all locations linked, participating with the following networks: BCA - BlueChoice PPO\nBAV - Blue Advantage HMO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-05-15","","","2024-05-15","Received email confirmation provider is PAR, eff. 05/15/2024, TIN and all locations linked, participating with the following networks: BCA - BlueChoice PPO\nBAV - Blue Advantage HMO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO. PA"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-06-18","Submitted application via delegated roster on 6/14/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-06-18","Submitted application via delegated roster on 6/14/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/14/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/14/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-17","Submitted Aetna application via delegated roster on 6/14/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-04-28","Application submitted for all 5 locations via secure portal. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/14/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/14/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-17","Submitted application for IMS via delegated roster on 6/14/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-17","Submitted application for IMS via delegated roster on 6/14/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-04-28","Facility Contract - No individual enrollment required as all billed services are done through the group, not the individual. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Payor Follow Up","2024-04-26","","","2024-05-20","Application submitted 04/29/2024. Allow more time. Allow 60-90 days for processing. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location wthompson"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location wthompson"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","1447899679","","2024-05-06","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Thru Other Payor","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-04-28","Group application is pending. If this is approved, a roster with all providers will be submitted at that time. Until the group application has been decided on, this is being placed on hold. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","2024-04-26","","","2024-05-20","Application submitted 04/29/2024. Allow more time. Allow 60-90 days for processing. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Payor Follow Up","2024-04-26","","","2024-05-20","Application submitted 04/29/2024. Allow more time. Allow 60-90 days for processing. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-04-28","Panel is closed to new providers. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/14/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-06-17","Submitted application via delegated roster on 6/14/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-06-19","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Thru Other Payor","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","2024-04-26","","","2024-05-21","Allow 180 days for processing. Submitted 04/29/2024. Still within timeframe. Allow more time. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Submitted","","","","2024-06-21","Location add pending under case#  09598462, per BCBSTX portal. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Thru Other Payor","Thru Other Payor","","","","2024-06-17","Submitted application via delegated roster on 6/15/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","2024-05-29","","","2024-05-29","Please see status updates under Alliance WC payor line. Jen Videan"]
["Kwame Boakye Agyeman, MD",1285863753,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2024-06-26","7598694","","2024-06-19","Provider has been enrolled and active eff 6/26/24. MS"]
["Kwame Boakye Agyeman, MD",1285863753,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","In Process","Application Submitted","","","","2024-06-17","Application submitted via online secure portal. MS"]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2024-05-30","","","2024-05-30","05/30/2024 CAQH Reattested added one location"]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-05-22","Certification submitted via secure portal or Briarwood location. Other locations will need to be added once the certification has been approved.  MS"]
["Mary Kay Ragan",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-05-22","Certification submitted via secure portal or Briarwood location. Other locations will need to be added once the certification has been approved.  MS"]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","2024-06-18","Application still pending per portal. PA."]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-18","App to update the group record has been submitted and is in processing. Once this has been approved, the providers record will automatically be updated at the same time. Nothing further is needed after that. MS"]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","2024-05-21","","","2024-06-03","Emailed TSCA and required documents to wwtxcontracts@texasmutual.com. Jen Videan"]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-05-22","Group holds a facility contract. Midlevels will bill services under the group info, not individually. MS"]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-05-22","Group holds a facility contract. Midlevels will bill services under the group info, not individually. MS"]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","2024-05-21","","","2024-05-31","Emailed roster to updates@primehealthservices.com. Jen Videan"]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45422,"6S2250","","2024-06-12","Received provider's welcome letter. MS"]
["Mary Kay Ragan",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-05-22","Pending Medicare approval. MS"]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","2024-05-21","","","2024-05-31","Application submitted via pswca.org. Jen Videan"]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","2024-05-21","","","2024-05-31","Please see status updates under Alliance WC payor line. Jen Videan"]
["Mary Kay Ragan",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","2024-05-21","","","2024-05-31","Please see status updates under Alliance WC payor line. Jen Videan"]
["Mary Kay Ragan",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-05-22","WTUC is not Tricare Credentialed and the network is not accepting new providers. MS"]
["Mary Kay Ragan",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-05-22","WTUC is not Tricare Credentialed and the network is not accepting new providers. MS"]
["Mary Kay Ragan",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45447,"1366816829","","2024-06-11","Welcome ltr rcvd. Provider effective 06/04/2024. Jen Videan"]
["Mary Kay Ragan",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","2024-05-21","","","2024-05-31","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Mary Kay Ragan",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-18","Group is not Tricare Credentialed and the payor is not accepting new providers at this time. MS"]
["Emma Elizabeth Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","Provider Load","DO NOT ENROLL","2024-06-14","","","2024-06-14",""]
["Emma Elizabeth Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-17","None of the 3 locations are Tricare credentialed, and since the panel is closed to new enrollments there is nothing else needed at this time. MS"]
["Emma Elizabeth Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","In Process","Application Resubmitted","","","","2024-06-19","Provider requires credentialing, so the request was submitted to Medical Onboarding. Provider ID 4469357. MS"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","HealthSmart PPO","Participating","Re-Credentialing",40575,"1356484497","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Liberty Mutual","Participating","Enrollment Complete",40541,"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","","Superior","Participating","Enrollment Complete","2019-10-01","1356484497","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","First Health Coventry","Participating","Enrollment Complete",44958,"3649611","","2023-03-08","03.06.2023 Per follow-up note - Provider is in network and linked under the TIN effective 02/01/2023. Next recredentialing is every 3 yrs from the effective date. Provider ID# 3649611. Physical location is on file.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","United Health Care","Participating","Enrollment Complete","2020-01-01","1356484497","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete status - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","1998-07-23","1356484497","","2020-07-20","7/20/2020- Received a spreadsheet from the payer stating this provider is effective as of 7/23/1998. – Jerha Gayorgor"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Scott&White (First Care)","Participating","Enrollment Complete","2017-12-03","1124009766","","2020-08-19","8/19/2020 - Rec'd the payer confirmation that 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\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hduak"]
["\"PK\" Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","First Health Coventry","Participating","Enrollment Complete","2008-09-01","1124009766","","2020-06-12","06/12/2020 - Rec'd email from the payer stating this provider is EFF - PID# 1620242 - Stacey Hudak"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-02","","","2024-01-09","Confirmed provider is linked to Ste. 271 via the self service portal. MS"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","CAQH","Participating","CAQH Reattested","2024-06-17","","","2024-06-17","06/17/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing",44665,"","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD",1225170103,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","1901-01-01","000466442","","2022-01-03","1/3/2022 Recevied email from asampat4@uhc.com, provider/group updates complete. Assigned reference number PR-6284499. Cbankston"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2021-12-06","","","2022-03-10","3/10/2022 Rcvd email from K. Avalos @ Galaxy that provider is PAR and linked to group TIN/location effective 12/06/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Re-Credentialing","2021-11-15","4361906","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD",1225170103,"75-2656723","TX","","First Health Coventry","Participating","Re-Credentialing","2021-11-15","1902363","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Humana","Participating","Enrollment Complete","2021-12-06","","","2022-04-21","4/21/2022 Per email received from VYoung at Humana delegated roster for December has been completed and providers loaded in Humana effective 12/6/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Re-Credentialing","2021-12-15","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Re-Credentialing","2021-12-06","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2021-12-06","1225170103","","2023-11-16","11/16/2023  In checking the TMJP portal the revalidation app has been completed.  Provider is PAR effective 12/1/2021.  Revalidation date - 10/11/2028.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2021-12-01","1X1311","","2021-12-08","12/8/21 Provider approved 12/01/2021. PTAN 1X1311 Cbankston"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Amerigroup","Participating","Enrollment Complete","2016-08-04","1528000734","","2020-03-20","03/20/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) stating this provider is EFF at this service location with Amerigroup - Stacey Hudak"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","USA PPO","Participating","Enrollment Complete","2002-11-15","1528000734","742348334","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["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"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Multiplan","Participating","Enrollment Complete","2017-04-15","1659366433","","2020-08-27","08/27/2020 - Rec'd email from the payer stating this provider is :  \"Thank you for contacting our Customer Service Department with Multiplan/PHCS. We received your request have confirmed that the following providers are participating with Multiplan and PHCS through Midland Pediatric Associates: - Willie Watson-Effective 04/15/2017\" - Stacey Hudak"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-07-26","","","2023-09-07","9/7/2023 Per email response from Mary Hanna at Aetna, May delegated roster is complete.  Provider is PAR and linked to group TIN/location effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-08-01","","","2021-10-11","10/11/21 Received email from FirstHealthCustomerServiceMailbox@AETNA.com that provider is participating with First Health Network effectice 8.1.21 with PID 1103233. Cbankston"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","2021-05-04","5/4/2021 Rcvd confirmation from Healthsmart <cgc.data@healthsmart.com> that provider is PAR and loaded under TIN and location effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","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","Aetna","Participating","Enrollment Complete","2021-07-26","7942472","","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 7/26/2021.  PID # 7942472 DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Multiplan","Participating","Enrollment Complete","2021-01-07","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Scott&White (First Care)","Participating","Enrollment Complete","2021-01-07","","","2021-04-22","4/22/2021 Rcvd roster from S&W and provider is participating and linked to TIN effective 01/07/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-02-02","Check Coventry portal for enrollment updates. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Corvel Healthcare Corp.","Participating","Enrollment Complete","","","","2023-11-27","Per Karina Garcia at Corvel, Lawrence Wilson, MD NPI: 1518951342- credentialing approved since 01/19/2022, renewal 01/19/2025. For billing purposes we always reflect back to the contract date which for this group is 7/20/2020. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Application Submitted","","","","2024-06-20","Submitted location add via delegated roster on 6/15/2024. PA."]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-01","","","2023-09-29","9/29/2023 Rcvd confirmation from Scott & White that provider has been loaded at all locations effective 9/14/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-18","Group enrollment has been submitted. If the payor wants to contract, they will reach back out and request a roster. There is no follow up needed. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-12-29","Per providerrelations@primehealthservices.com records have been updated and provider has been retro-dated back to contract effective date of 05/23/2023. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-10-02","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21",""]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","HealthSmart PPO","Participating","Enrollment Complete","2021-01-07","","","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",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","Alliance WC","Participating","Enrollment Complete","2023-12-01","","","2023-12-18","Welcome letter rcvd. Provider eff 12/01/2023. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2021-01-07","","","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",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2021-08-13","","","2022-02-07","2/7/2022 Rcvd roster from Multi plan listing provider as PAR and linked to group TIN/location effective 8/13/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete","2021-01-07","","","2021-06-04","6/4/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Omni PPO","Participating","Enrollment Complete",44203,"","","2021-06-15","6/15/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for March, April, May and June have been completed.  Provider is PAR and linked to location/TIN effective 1/7/2021. DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","CAQH","Participating","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location wthompson"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - City of Midland Health Department","CAQH","Participating","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location wthompson"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location wthompson"]
["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,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","Amerigroup","Participating","Enrollment Complete","2021-01-07","","","2021-12-03","12/3/2021 Per Amerigroup roster received Joe Rodriguez provider is PAR under group TIN/location effective 1/7/2021.   DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2021-11-16","002438204","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 11/16/2021.  MPIN # 002438204.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","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","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","002438204","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 11/16/2021.  MPIN # 002438204.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-18","Group is not Tricare Credentialed and the payor is not accepting new enrollments at this time. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-25","Confirmed provider is linked to Briarwood location effective 9/20/2023. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-01","","","2023-12-18","See Alliance WC payor line for details. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",44419,"","","2024-03-22","Per BCBSTX roster, provider listed PAR, effective 8/11/2021, participating with the following networks: Blue Advantage HMO, \nBlueChoice PPO, Health Select, Blue Essentials HMO, and Medicare Advantage\nPPO. PA"]
["Lawrence A Wilson, MD",1518951342,"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"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","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"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Re-Credentialing","2011-02-01","10120298","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","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","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (hpdelegation@bswhealth.org) requesting update on enrollment status. PA."]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","CAQH","Participating","CAQH Reattested","2024-06-05","","","2024-06-05","06/05/2024 all locations current and all expirables up to date wthompson"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","United Health Care","Participating","Enrollment Complete","2023-12-11","00003456174","","2024-01-22","1/22/2024 Per UHC portal provider is PAR and linked to group TIN/location effective 12/11/2023. MPIN# 00003456174.  DCannon"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","HealthSmart PPO","In Process","Payor Follow Up","","","","2024-01-29","1/29/2024 Sent follow-up email to Aleece Moerbe at Healthsmart requsting an update of provider load.  DCannon"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete","2013-11-01","1942216122","","2020-07-17","7/17/2020- Received a spreadsheet from the payer stating this provider is effective as of  11/1/2013. – Elonah Grace B. Gelig"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Rail Road Medicare","Participating","Enrollment Complete","2001-08-01","P02417357","CI6074","2020-08-28","08/28/2020 - moved to completed status after finding EFF letter in the payer portal - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","","USA PPO","Participating","Enrollment Complete","2002-11-15","1073555249","742348334","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","","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.\""]
["Govind B Patel, MD",1073555249,"74-2348334","TX","","CAQH","Participating","CAQH Reattested","2024-06-05","10594793","","2024-06-05","06/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Multiplan","Participating","Enrollment Complete","1996-10-01","1073555249","","2020-02-12","02/12/2020 - rec'd confirmation through payer portal that this provider is EFF through and INDIVIDUAL CONTRACT as of 10-1-1996. Provider is in network with multiplan - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","","Humana","Participating","Enrollment Complete","2013-09-15","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/15/2013.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2023-06-01","","","2023-08-23","8/23/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-06-01","","","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 6/1/2023.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2023-10-18","3453380","","2023-10-19","Received enrollment confirmation. MS"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2023-06-01","1119106","","2023-09-20","9/20/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 6/1/2023.  PID #1119106.  DCannon"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-05-25","","","2024-01-25","During the Tricare audit, it was found the provider is credentialed and in network with Tricare effective 5/25/2023. MS"]
["Joseph J Shayeb, MD",1528049590,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",45078,"","","2023-10-27","10/27/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 6/1/2023.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2014-04-01","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna","Participating","Enrollment Complete","2013-08-01","1013923291","","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 8-1-2013 under a DIRECT CONTRACT at this service location. - Stacey Hudak"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","In Process","Pending Contracting","","","","2024-04-23","See Broadspire under group record for updates. Jen Videan"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Enrollment Complete","2019-07-19","02709262","","2021-05-04","5/4/2021 Rcvd roster from Amerigroup listing provider as PAR and in network effective 7/19/2019.  DCannon"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete",39692,"1098298","","2020-03-20","03/20/2020 - Rec'd an email from the payer stating this provider is EFF under this TIN. Email shared provider ID# 1098298 - Stacey Hudak"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","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"]
["Shylesh R Ganta, MD",1811900657,"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"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Cigna","Participating","Enrollment Complete","2013-03-01","1770564080","","2020-04-21","04/21/2020--S/W Francis of Cigna @ 8008824462, provider NPI is on file for the provider and participating effective 03/01/13 under the group and TIN with direct contract. Physical location is on file. Provider ID#6815546. Call ref# FRANCIS0421.\n--copied note from spreadsheet-tisha rader"]
["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","Galaxy Health","Participating","Enrollment Complete",43709,"1760485502","","2020-08-21",""]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","CAQH","Active","In House Enrollment","2020-05-29","","","2023-02-12","2/12/2023 CAQH maintained by provider.  DCannon"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Sedgwick","Participating","Enrollment Complete","2011-09-01","1295724698","752656723","2020-08-19","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2013-04-08","","","2024-04-29","Re-Cred has been approved eff 4/5/2013. MS"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2002-10-01","1295724698","Multiple Group Affiliations","2020-04-09","04/09/2020 - Rec'd response from the payer stating:\n\"Thank you for contacting our Service Department at Multiplan/PHCS and Beech Street. Here is the following information we have on file for Patel, Kirit:\n\nNetwork: Multiplan\nNetwork Participation effective: 10/01/2004\nContract Source Group contract through: West Texas Physicians Alliance \n\nNetwork: PHCS\nNetwork Participation effective: 10/01/2002\nContract Source Group contract through: West Texas Physicians Alliance \n\nNetwork: Beech Street\nNetwork Participation effective: 01/01/2008\nContract Source Group contract through: West Texas Physicians Alliance\n\nNetwork: Multiplan and PHCS\nNetwork Participation effective: 02/28/2017\nContract Source Group contract through: Permian Basin Healthcare Network-Midlevel\n\nNetwork: Multiplan, PHCS, and Beech Street \nNetwork Participation effective: 11/01/2010\nContract Source : Individual\"\n\nStacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2011-09-01","1295724698","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Liberty Mutual","Participating","Enrollment Complete","2011-09-01","1295724698","752656723","2020-08-19","Confirmed provider is participating with WIN network, which includes this payor (list of networks attached). Kimberly Frazier"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2011-09-01","1295724698","752656723","2020-08-19","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimbery Frazier"]
["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","Omni PPO","Participating","Enrollment Complete","2021-10-29","1912100850","","2023-08-24","8/24/2023 Per email received from IMS/Omni provider is PAR and linked to group TIN/location effective 10/29/2021.  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"]
["P Douglas Cochran, MD",1316026396,"20-0212181","TX","P. Douglas Cochran, MD, PA","Cigna","Participating","Enrollment Complete","2023-05-01","","","2023-11-03","Received confirmation of update. W202310193478451 MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2016-02-09","","","2024-01-11","Dr. Beck is effective at 210 W. Longview Ave Ste A, Bldg A Effective 02/09/2016. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",42409,"","","2024-01-11","Dr. Beck is effective at 210 W. Longview Ave Ste A, Bldg A Effective 02/09/2016. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",42409,"","","2024-02-16","Per Michelle Killough @ Alliance WC provider is effective 02/19/2016.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-05","","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/05/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45174,"","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/05/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","United Health Care","Participating","Enrollment Complete","2020-01-01","00002067277","","2023-10-13","10/13/2023 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 1/1/2020.   MPIN# 00002067277.   DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-11","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-10-01","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-01-01","","","2024-01-18","Received confirmation of enrollment. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2016-10-26","","","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 10/26/2016.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-18","App to update the group record has been submitted and is in processing. Once this has been approved, the providers record will automatically be updated at the same time. Nothing further is needed after that. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-29","","","","05/29/2024 CAQH Reattested added one location wthompson"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-08-02","","","2023-09-26","Per providerdata@careworks.com all three locations added Effective 08/02/2023. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2015-05-09","P01841282","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Scott&White (First Care)","Participating","Enrollment Complete","2009-01-01","1912991084","","2020-08-20","08/20/2020 - Rec'd email from the payer stating this provider is affiliated with PRIMED DELEGATED AGREEMENT under this TIN/Service Location. \nThe provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-11-05","Provider linked to Andrews Hwy location eff 10.26.2023"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-23","Confirmed Briarwood location is linked to provider. effective 7/28. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2016-02-19","","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2016-02-19","","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2015-07-28","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 7/28/2015.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-06-19","","","2023-07-18","7/18/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave effective 6/19/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2024-04-26","Sent email to Cassandra Dunagan- Smith requesting assistance with adding locations. PA"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-31","Check Coventry portal for enrollment updates. MS"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Enrollment Complete","2004-10-01","1578557468","","2022-10-03","10/3/2022 Per TMHP web portal provider is PAR and linked to group effective 10/1/2004.  TPI# 1578557468.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","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","IMS","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 October has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-11-01","","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2022-09-13",""]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","In House Enrollment","","","","2022-09-13",""]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44817,"","","2023-05-24","Confirmed via HM portal. MS"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2022-09-12","","","2022-12-29","12/29/2022 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-10-07","","","2022-10-28","10/28/2022 Rcvd email from Scott & White that provider is PAR and linked to group TIN/locations effective 10/7/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","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","Medicare","Participating","Enrollment Complete","2022-09-12","2I8228","0008AH","2022-09-21","9/21/2022 Rcvd Medicare approval letter from Candace Wynne.  PTAN # 2I8228 - effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-12","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Vincent P Rascon, DPM",1346236924,"91-1559006","TX","PE - Vincent P. Rascon","Triwest VA","Terminated","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider is effective 8/1/22"]
["Vincent P Rascon, DPM",1346236924,"91-1559006","TX","PE - Vincent P. Rascon","Medicare","Terminated","Enrollment Complete","1998-06-01","00147E","N/A - no group enrollment/PTAN","2020-03-10","03/10/2020 - Logged onto provider account through PECOS and found that this provider only has an individual enrollment. Is not reassigned to group - Stacey Hudak"]
["Vincent P Rascon, DPM",1346236924,"91-1559006","TX","PE - Vincent P. Rascon","Rail Road Medicare","Terminated","Enrollment Complete","1997-10-01","480027409","N/A - no group link/PTAN","2020-03-10","03/10/2020 - Found EFF info through payer portal - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","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"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1730181389","","2020-07-01","07/01/2020 - rec'd email confirmation from the payer that this provider is EFF - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","HealthSmart PPO","Participating","Enrollment Complete",37347,"","","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,"26-3789190","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,"26-3789190","TX","PE - Permian Physician Services","Medicaid","Participating","Enrollment Complete",44197,"137280711","205408201","2021-04-14","4/14/2021 Rcvd TMHP Approval letter from Stacy Salazar that provider has been linked to Permian Physician Services TMHP group #.  TPI # 137280711 effective 1/1/2021"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1730181389","","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"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Alliance WC","Participating","Enrollment Complete",45233,"","","2023-11-20","Rcvd approval ltr. Provider effective 11/03/2023. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Zurich","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Facility Enrollment","Facility Enrollment","","112273103","","2020-09-23"," 09/23/2020 - Rec'd email from the clinic with the group RHC TPI# 112273103.  Moved to effective status to bring payer line to a desired status. THIS IS A FACILITY ENROLLMENT - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Liberty Mutual","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2022-01-12","001199099","","2022-02-09","2/9/2022 Received email from united_healthcare_provider_operations@uhc.com, provider/group updates are complete. PID 001199099. Reference number PR-6309606. Sent email to network services requesting eff date. Cbankston"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete",38292,"1730181389","","2020-07-31","7/31/2020 - Rec'd email from the payer stating \"I also show Rand attached to Permian, effective 11/1/04. \" - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Texas Mutual","Participating","Enrollment Complete",45383,"","","2024-04-05","Approval ltr rcvd. Effective 04/01/2024. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Liberty Mutual","Participating","Enrollment Complete",37663,"1730181389","751997880","2020-08-19","Confirmed provider is participating with WIN networks which includes this payor (list of networks attached). Kimberly Frazier"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","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","Sedgwick","Participating","Enrollment Complete","2002-11-15","1316965403","562697415","2020-08-21","Confirmed provider is participating with WIN networks, which includes this payor (list of networks attached). Kimberly Frazier"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","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","Galaxy Health","Participating","Enrollment Complete",44235,"","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 02/08/2021.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Humana","Participating","Enrollment Complete","2018-08-31","","","2021-03-09","3/9/2021 Per \"Comform Par Status\" notes the provider is participating under the group and TIN# effective 8/31/2018, physical location is on file.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","First Health Coventry","Participating","Re-Credentialing",42552,"1093821274","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Zurich","Participating","Enrollment Complete",43670,"","","2020-09-10","9/10/2020 Confirmed provider is participating with Coventry Integrated Network under delegation with location on file. Kimberly Frazier"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Aetna","Participating","Re-Credentialing","2014-11-15","1093821274","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","","TriCare Standard","Participating","Enrollment Complete","2019-08-03","1780892760","","2020-07-09","07/09/2020 - Rec'd access to the group in the payer portal and I was able to confirm that this provider is EFF - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Humana","Participating","Enrollment Complete",43586,"1780892760","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","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","TX","","Amerigroup","Participating","Enrollment Complete",43936,"07110928","","2021-02-13","2/13/2021 - Verification on payer website Amerigroup.healthsparq.com provider is participating and linked to TIN and location for the following plans CHIP, CHIP-PERINATAL, STAR, STAR-KIDS, STAR-PLUS.  DCannon"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1780892760","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Anand C Reddy, MD",1780892760,"81-3411343","TX","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","TX","","Superior","Participating","Enrollment Complete","2020-10-01","1780892760","","2020-10-01","10/01/2020 - rec'd email from the payer stating this provider has been updated and made EFF off the roster - Stacey Hudak"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Provider Load","CAQH Reattested","2024-06-24","","","2024-06-24","CAQH Sweep updated email, cred contact, billing location and COI. Uploaded docs wthompson"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Provider Load","Provider Load","2024-06-24","","","2024-06-24",""]
["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","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","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","Ambetter","Participating","Enrollment Complete",44652,"","","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","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-05","8/5/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","IMS","Participating","Enrollment Complete","2021-06-01","","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","9672268","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 9672268  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","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","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-04","8/3/2021 Medicare enrollment is done in-house by MCHS.  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","2012-10-29","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 10/29/2012.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2023-05-08","","","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 5/8/2023.  DCannon"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2023-09-21","6920089","","2023-10-19","10.17.2023 S/W Wyn of Cigna @ 1-800-882-4462. Per rep, Per rep, Provider is in network with Cigna and linked to the group and TIN# effective 09/21/2023. Next recredentialing date is on 09/21/2026. PIN: 6920089. Servicing location is on file. No payer# available. Call ref# Wyn10172023. - Willie Ravas"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","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"]
["Marcy L Askins, FNP-C",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-11-01","","","2023-11-06","11/6/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 11/1/2023.  DCannon"]
["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","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","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","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","Cigna","Participating","Enrollment Complete","2021-06-01","815933","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 815933. KFrazier"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","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"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2016-08-23","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","Omni PPO","Participating","Enrollment Complete","2019-09-01","1306167309","","2020-07-27","IMS complete"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete",43709,"1306167309","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","CAQH","Participating","CAQH Reattested",45448,"","","2024-06-05","06/05/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","IMS","Participating","Enrollment Complete","2023-01-09","","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 1/9/2023.   DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","Cigna","Participating","Enrollment Complete","2023-09-19","","","2023-10-12","Contract has been signed and executed. MS"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","First Health Coventry","Participating","Enrollment Complete","2023-01-09","","","2023-08-17","8/17/2023 Per First Health web portal provider is PAR and linked to group/location effective 1/9/2023.  PID # 1961903.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2024-01-16","1/16/2024 Pending Multiplan enrollment.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","Tricare Prime","Participating","Enrollment Complete","2023-06-02","","","2024-01-25","Confirmed via the Tricare portal, the provider is Credentialed and In Network. MS"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1306162557","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center 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"]
["Asif AK Ansari, MD",1528299872,"81-3411343","tx","PE - Permian Basin Kidney Center Inc","HealthSmart PPO","Participating","Enrollment Complete",43740,"10-2-2019","","2020-07-21","07/21/2020 - Rec'd email from the payer stating this provider is EFF with this TIN/service location under the WEST TEXAS PHYSICIANS ALLIANCE MDDO\ndelegation - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Boon Chapman","Participating","Enrollment Complete","2020-04-01","1528299872","","2020-10-05","Enrollment thru PHCS"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","United Health Care","Participating","Enrollment Complete","2019-10-25","1528299872","","2020-06-09","06/09/2020 - Rec'd email from this payer stating \"Delegated for this TIN with Permian Basin Healthcare Network\" - stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","IMS","Participating","Enrollment Complete","2019-10-01","1528299872","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","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","Humana","Participating","Enrollment Complete",43620,"","","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","","Cigna","Participating","Enrollment Complete","2019-06-14","1528299872","","2020-04-22","04/22/2020--SW Sharon of Cigna @ 8008824462, Provider NPI# is on file and participating under the group and TIN# effective 6/14/2019. Location is on file. Call ref# Sharon4202020.\n-copied note from spreadsheet-tisha rader"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1528299872","","2020-09-14","09/14/2020 - 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"]
["Asif AK Ansari, MD",1528299872,"81-3411343","tx","PE - Permian Basin Kidney Center Inc","Ambetter","Participating","Enrollment Complete","2023-08-01","","","2023-08-15","8/15/2023 Rcvd confirmation email from Superior that July delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group/location effective 8/1/2023.  DCannon"]
["Alaaedin Alhomosh, MD",1063709913,"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"]
["Alaaedin Alhomosh, MD",1063709913,"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"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-11-27","P01782054","DW7662","2020-12-31","11/31/2020 Confirmed provider is already participating and assigned RR PTAN P01782054 effective 11/27/2016. KFrazier"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2016-11-27","338869610","364596201","2020-12-31","12/31/2020 Confirmed provider is participating and assigned TPI 338869610 under group. Revalidation due 12/21/2022. KFrazier"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",43111,"","","2020-10-23","10/23/2020 Provider is participating with TriCare Prime; therefore, remains certified as a non-network effective 1/11/2018. Kimberly Frazier"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2018-03-05","1295109510","","2020-03-17","03/17/2020 - Rec'd an email from the payer contaning a spreadsheet showing this service location as effective - Stacey Hudak"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested",45449,"13683951","","2024-06-06","06/06/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-04-22","Per TMHP request has been closed and provider is enrolled. 400 Rosalind Redfern Grover Pkwy STE 200, Midland, TX, 79701-5852 and 600 Washington Ln, Odessa, TX, 79761-7011 effective 03/14/2023. Jen Videan"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","361608801","079837301","2020-01-29","01/29/2020 - this provider is enrolled; verified through the payer portal.  This provider is linked to 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"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1295109510","","2020-07-27","IMS complete"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",42466,"1295109510","West Texas Physicians Alliance","2020-09-28","09/28/2020 - Rec'd emailed spreadsheet showing this provider is EFF with these networks: Multiplan/PHCS/BeechStreet but under the delegation with: West Texas Physicians Alliance - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete",42522,"","","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","Amerigroup","Participating","Re-Credentialing","2021-02-12","1215254156","","2024-04-19","4/19/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2016-12-19","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  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","","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","USA PPO","Participating","Enrollment Complete","2015-05-12","1467745240","752656723","2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2019-08-14","1467745240","","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",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","","Tricare Prime","Participating","Enrollment Complete","2020-01-01","","","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"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","Pending Info/Document","2024-04-10","13510925","","2024-04-10","04/10/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-05","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 7/5/2023.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Application Resubmitted","2023-07-05","8143656","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1770883191","","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",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2015-10-15","1770883191","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2015-10-15","1770883191","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2018-08-10","1770883191","","2020-06-05","06/05/2020 - rec'd email from the payer stating provider is EFF - stacey Hudak"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","1770883191","","2024-06-20","Revalidation approval letter rcvd. Jen Videan"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2015-10-26","1770883191","","2020-06-25",""]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","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"]
["Michael J Hester, APRN-AGACNP",1275044422,"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"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2018-07-31","1275044422","752656723","2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","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","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-02-13","1275044422","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",43191,"662202","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","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"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2018-07-24","","","2021-10-21","10/21/2021  Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 7/24/2018.  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","Humana","Participating","Enrollment Complete","2015-12-08","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 12/8/2015.  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","IMS","Participating","Enrollment Complete","2014-02-07","1013990761","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - 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","Cigna","Participating","Enrollment Complete",44348,"6653474","","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 6653474. KFrazier"]
["Eliseo Rivera, MD",1013990761,"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."]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","1013990761","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","USA PPO","Participating","Enrollment Complete","2020-04-03","","","2022-04-09","4/09/2022 Per roster from USA MCO provider is PAR and linked to group TIN/location effective 4/3/2020.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","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"]
["Karen Ward, APRN-NP, RNFA",1790831493,"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"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2022-08-15","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, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-18","7/18/2023 Rcvd email from Cigna that provider is PAR and linked to new practice locations effective 5/1/2023.  PID # 8228233 DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Re-Credentialing",45201,"","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2022-08-26","","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-12-21","Panel is still currently closed until further notice. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-08-02","","","2024-04-25","4/25/2024 provider enrolled as of 8/2/2023 via roster. FC"]
["Karen Ward, APRN-NP, RNFA",1790831493,"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"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-5554737","TX","","USA PPO","Participating","Enrollment Complete","2021-04-13","","","2021-09-07","9/7/2021 Rcvd roster from USA PPO listing provider as PAR w/ group TIN/locations effective 4/13/2021.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2023-09-01","9/1/2023 Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-25","1790831493","","2024-05-17","Per Dee Dee Johnson at Texas Mutual, site visit completed and added to record. Effective 03/25/2024. Jen Videan"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2024-04-26","Sent email to Cassandra Dunagan- Smith requesting assistance with adding locations. PA"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-09-01",""]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Re-Credentialing","2022-07-01","2703063","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-04-06","","","2021-06-04","6/4/2021 Per Karen Avalos at Galaxy Health monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective 4/6/2021.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Re-Credentialing","2021-04-13","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Re-Credentialing",44743,"5951375","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Re-Credentialing",44743,"5951375","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2022-05-01","","","2023-09-08","Confirmed enrollment with all locations under WesTex. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Payor Follow Up","","","","2024-06-21","Sent email requesting group roster from UHC. PA."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",44682,"","","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, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45189,"","","2023-09-26","Confirmed provider is linked to Briarwood location effective 9/20/23. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Application Submitted","","","","2024-06-20","Submitted location add via delegated roster on 6/15/2024. PA."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Re-Credentialing","2023-05-01","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Re-Credentialing","2020-01-01","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2022-08-26","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 08/26/2022.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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, APRN-NP, RNFA",1790831493,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-05-23","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 5/23/2021.  DCannon"]
["Stephen P Dodd, PA",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Application Resubmitted","2017-05-01","1598976011","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Stephen P Dodd, PA",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete",41849,"1598976011","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 7/29/2014 - Jesriel Segovia"]
["Stephen P Dodd, PA",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Humana","Participating","Enrollment Complete",42856,"1598976011","","2020-08-31","08/31/2020 - moved to completed status afer reviewing follow up complete note - under PRIMED - Stacey Hudak"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-07-07","3218941","","2021-07-09","7/9/2021 Received an email from discovercigna@information.cigna.com confirming provider is now participating under group Tax ID effective 7/7/2021 with assigned provider ID 3218941. KFrazier"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-01-17","","","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",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Application Resubmitted","2019-09-01","1437175163","","2024-06-17",""]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","Humana","Participating","Enrollment Complete","2011-03-01","1134151756","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","","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"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","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"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Humana","Participating","Enrollment Complete","2017-05-01","1184727562","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note - 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","","IMS","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Re-Credentialing","2023-09-06","002854139","","2024-02-19","2/19/2024 - submitted recred status via delegated monthly roster on 02/15/2024. PA."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-12-01","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2014-02-15"," 9326179","","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",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Re-Credentialing","2023-05-01","9326179","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete",45139,"","","2023-10-10","Received confirmation of the locations being added. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",43664,"13403339","","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",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2024-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","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",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Submitted","","","","2024-06-21","Location add pending under case#  09598462, per BCBSTX portal. PA."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-02-01","","","2024-05-10","Received email confirmation from shpdelegation@superiorhealthplan.com, provider is par and linked to TIN/location, eff. 02/01/2024. PA"]
["Johnny L Flitton, PA",1437356730,"47-3465832","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",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2023-12-21","","","2024-01-02","Approval letter rcvd. Provider is effective 12/21/2023. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location approved eff 10/9/23. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-26","Confirmation received  the provider is linked to Briarwood location effective 9/20/23. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location approved eff 10/9/23. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-09-06","","","2023-10-11","10/11/2023 Per email received from Galaxy September delegated roster has been processed and provider is PAR and linked to group/location effective 9/6/2023.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-10-10","","","2023-10-09","10/9/2023 Rcvd email from Priscilla at MQA confirming provider is PAR and linked to group effective 10/10/2023.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-10-13","10/13/2023 Provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2019-07-18","13403339","","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",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Enrollment on Hold","Enrollment on Hold","2024-05-29","","","2024-06-10","Pending site visit. Please see status updates under group record payor line. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-09-06","","","2023-10-09","10/9/2023 Per email received from G. Aviles at IMS/OMNI September delegation roster has been completed.  Provider is PAR and linked to group/location effective 9/6/2023.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",43924,"","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 4/3/2020.  DCannon"]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",43831,"1437356730","","2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",43435,"","","2023-10-12","10/12/2023 Per email received from Scott & White provider is PAR and linked to group TIN/locations effective 12/1/2018.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Re-Credentialing","2023-09-06","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Re-Credentialing","","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Johnny L Flitton, PA",1437356730,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2008-04-02","1437356730","","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",1437356730,"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.\""]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Re-Credentialing","2023-09-06","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Superior","Participating","Enrollment Complete","2019-03-01","1437356730","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF with this TIN under PRIMED DELEGATED agreement - Stacey Hudak"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Payor Follow Up","","","","2024-04-26","Sent email to Cassandra Dunagan- Smith requesting assistance with adding locations. PA"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2015-05-09","423893ZP5M","","2020-06-15","06/15/2020 - Rec'd spreadsheet from the clinic stating this provider is EFF - Stacey Hudak"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-29","12235261","","2024-04-25","04/25/2024 Added one location. All expirables up to date wthompson"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-29","12235261","","2024-04-25","04/25/2024 Added one location. All expirables up to date wthompson"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-08-02","P01752740","DW7662","2020-05-04","05/04/2020 - verified and marked EFF - Stacey Hudak"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","Pending Info/Document",45203,"","","2024-01-25","01/25/2024 Cannot reattest CAQH missing Username and password. wthompson"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","CAQH","Active","CAQH Reattested","2024-06-06","13752595","","2024-06-06","06/06/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["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","","Aetna","Participating","Enrollment Complete","2020-12-01","","","2020-11-07","11/6/2020 Received email from ProviderCommunications@aetna.cpe.messages2.com confirming provider is participating under group Tax ID effective 12/1/2020 and assigned PIN number 9631791. Kimberly Frazier"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-03-29","194527101","079837301","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",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2008-05-13","1760501720","","2020-06-25",""]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","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","","Cigna","Participating","Enrollment Complete","2010-09-20","1760501720","","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",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","","Galaxy Health","Participating","Enrollment Complete","2014-05-12","1760501720","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2015-04-29","01448885","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 3/1/2012; Medicare - eff 8/1/2012; C-SNP - eff 1/1/2017; Other - eff 1/1/2021, Plus - eff 3/1/2012, Star_Kids - eff 11/1/2016.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2019-09-01","1093937948","","2020-07-27","IMS complete"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","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","TX","","First Health Coventry","Participating","Enrollment Complete","2011-02-01","1594366","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2018 2/1/2011 PID # 1594366-tisha rader"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2009-03-24","194906703","079837301","2020-03-13","03/13/2020 - Clinic forwarded Medicaid TMHP approval letter showing where the provider was linked to the group - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2011-02-01","1594366","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2018 2/1/2011 PID # 1594366-tisha rader"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2015-04-29","1093937948","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2008-11-01","P00716501","","2020-03-30","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2008 with provider number P00716501. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","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","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","TX","","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","TX","PE - Premier Family Care, Inc","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,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2014-12-01","2681483","","2023-09-05","9/5/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 12/1/2014.  PID #2681483  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2020-05-13","8867748","","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",1376723361,"47-3465832","TX","","Scott&White (First Care)","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Rail Road Medicare","Pending Other Enrollment","Pending Other Enrollment","","","","2024-05-14","Pending group enrollment. Request letter submitted 5/14/2024. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-18","Group enrollment has been submitted. If the payor wants to contract, they will reach back out and request a roster. There is no follow up needed. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","USA PPO","Participating","Enrollment Complete","2018-02-04","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","United Health Care","Participating","Enrollment Complete","2020-08-22","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/22/2020.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Wellmed","Thru Other Payor","Payor Follow Up","","","","2024-06-21","Sent email requesting group roster from UHC. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","HealthSmart PPO","Participating","Enrollment Complete","2016-04-25","13512484","","2020-07-21","07/21/2020 - rec'd spreadsheet from the payer stating this provider/TIN/service location is EFF - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Gallagher","Delegated - Third Party","Add to Next Delegated Roster","2015-12-01","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2022-01-01","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 1/1/2022.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","IMS","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-04-09","13780299","","2024-05-29","incorrect username or password cannot reattest"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-04-09","13780299","","2024-05-29","incorrect username or password cannot reattest"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-04-09","13780299","","2024-05-29","incorrect username or password cannot reattest"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-04-09","13780299","","2024-05-29","incorrect username or password cannot reattest"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-01","1376723361","","2020-07-27","IMS complete"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-26","","","2024-03-06","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/26/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-09-26","","","2024-03-06","Per brandhi_wilson-woods@corvel.com provider is approved effective 09/26/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1376723361","","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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location confirmed eff 10/9/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-09-26","Confirmed provider is linked to Briarwood location effective 9/20/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location confirmed eff 10/9/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","Omni PPO","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-10-18","10/18/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","USA PPO","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","Aetna","Participating","Enrollment Complete",45096,"9469407","","2023-10-19","10.16.2023 S/W Chris of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective on 06/19/2023. No next recredentialing date available. PIN: 9469407. Servicing location is on file. Payer# 60054. Call ref# 6166862305. - Willie Ravas"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","USA PPO","Participating","Enrollment Complete",43135,"","","2023-11-20","11/20/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 2/4/2018.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not showing on the Coventry portal. Please add to next delegated roster submission. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not showing on the Coventry portal. Please add to next delegated roster submission. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",42984,"P01938882","DX4335","2020-07-10","07/10/2020 - was able to confirm EFF info through payer site - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Zurich","Delegated - Third Party","Add to Next Delegated Roster","2015-12-01","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","United Health Care","Participating","Enrollment Complete","2020-08-22","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/22/2020.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","United Health Care","In Process","Application Submitted","2024-05-29","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Corvel Healthcare Corp.","In Process","Pending Other Enrollment","2024-05-29","","","2024-06-10","Please see status updates under group record payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","In Process","Payor Follow Up","","","","2024-05-28","Inquired on network status via email to coventryproviderupdates@cvty.com . FC"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2017-09-01","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2017-09-01","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-03-09","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 3/9/2017.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2017-03-09","","","2023-10-02","10/2/2023 Per BCBS TX roster received from Priscilla Albertine at MQA provider is PAR and linked to group effective 3/9/2017.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete",44652,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR for Ambetter product and linked to group delegation roster effective 4/1/2022."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 03/27/2020 Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 03/27/2020 Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-12-05","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Effective 03/27/2020 Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-01-03","","","","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 1/3/2022.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Add to Next Delegated Roster","","","","2024-01-27","Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","HealthSmart PPO","Participating","Enrollment Complete","2023-10-02","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider effective 02/21/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Superior","Participating","Enrollment Complete",43160,"1376723361","","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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","First Health Coventry","Participating","Enrollment Complete",41974,"2681483","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 12/1/2014 PID # 2681483\ntisha rader"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Galaxy Health","In Process","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-18","Group is not Tricare Credentialed and the payor is not accepting new providers at this time. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Cigna","Facility Enrollment","Enrollment Complete",45047,"","","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","","Scott&White (First Care)","Participating","Enrollment Complete","2018-05-18","1376723361","","2020-08-19","8/19/2020 - Rec'd spreadsheet from the payer confirming that this provider is affiliated with the PRIMED DELEGATED agreement under this TIN/Service Location. THis provider is networked with: \nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Broadspire Services Inc.","In Process","Pending Other Enrollment","2024-05-29","","","2024-06-03","Please see status updates under group record payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",45345,"","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete",40969,"1790972610","","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"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Aetna","Participating","Enrollment Complete",40330,"1790972610","","2020-03-26","3/26/2020--SW Ali of Aetna @ 800-353-1232. NPI is on file for the provider and is participating effective 6/1/2010 under group and TIN. DIRECT CONTRACT with Aetna. Physical location is on file. Call ref# 5196002602.\ntisha rader"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing",43906,"1447415476","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete",43936,"1447415476","","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"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2017-07-10","P01909454","","2020-03-25","3/25/2020--Per online check, provider is now PAR effective 07/10/2017 with provider number P01909454. Attached welcome letter to payor line\ntisha rader"]
["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",40575,"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"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","In Process","Application Submitted","","","","2024-05-31","Application to link this provider has been submitted via the Tricare portal. MS"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45369,"9630068","","2024-06-18","S/W Claire of Edward @ 1-800-353-1232. Per rep, Provider is in network with Aetna for the state of TX and linked to the group and TIN effective 03/18/2024. No next recredentialing date provided. PIN: 9630068. Servicing location is on file. Payer# 60054. Call ref# 6194642485."]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Multiplan","No Value Specified","Add Info Submitted","","","","2024-06-18","Submitted delegated roster on 6/14/2024. FC"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",45264,"","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 12/04/2023. PA."]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",45327,"","","2024-03-20","03/20/2024 - per UHC Optum Behavioral rep Mars, 1-877-614-0484, ref# MARS32024, provider is PAR, eff. 02/05/2024. Location 2402 W Wall confirmed listed. PA."]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Payor Follow Up","","","","2024-05-22","Follow up secheduled for 05/25/2024, requesting enrollment status update, case# CO-17199399. PA."]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","","Cigna","Participating","Enrollment Complete",45371,"60308","","2024-03-22","03.22.2024 WR: Called Cigna@ 1-800-882-4462 to obtain PNP/FU status for the provider and spoke to PaulaM. Per rep, Provider is in network with Cigna for the state of TX and linked to the group and TIN# effective 03/20/2024. Next recredentialing date is on 03/20/2027. PIN: 0998740. Servicing location is on file. Payer# 60308. Call ref# PaulaM03242024."]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","2024-01-01","","","2024-04-24","4/24/2024 Spoke to Shannon call ref#1025129 provider effective as of 1/1/2024 under Child & Adolescent Psychiatry/Psychiatry. FC"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2011-09-01","1376556019","","2020-06-25",""]
["Staton Awtrey, MD",1376556019,"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"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",41274,"","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 12/31/2012.  DCannon"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",40969,"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"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",42500,"","","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 5/10/2016.  DCannon"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",42522,"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",1558392779,"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"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Re-Credentialing",40575,"1558392779","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",40335,"3015766","","2020-06-08","06/08/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete",43980,"","","2020-11-17","11/17/2020 - Checked the Humana-Military website provider credentialing is completed effective 5/29/2020.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete",44044,"1174846364","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","Participating","Enrollment Complete",43709,"1174846364","","2020-07-27","IMS complete"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Terminated","Terminated",44562,"1881711778","","2023-10-25","10/25/2023 Per email received from Priscilla Albertine at MQA, Dr. Wolbert's UHC contracted terminated effective 8/23/2023.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Humana","Participating","Enrollment Complete",42856,"1881711778","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","HealthSmart PPO","Participating","Enrollment Complete","2021-08-02","1881711778","","2021-10-06","10/6/2021 Per Healthsmart website provider is PAR and loaded under TIN/location effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","Participating","Enrollment Complete","2020-04-15","01618929","","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"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Medicaid","Participating","Enrollment Complete","2010-07-25","284181901","","2023-09-18",""]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Multiplan","Participating","Enrollment Complete","2021-08-13","1881711778","","2021-09-15","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Participating","Enrollment Complete","2010-03-01","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Medicare","Participating","Enrollment Complete","2010-07-25","TXB111410","00608K","2020-05-04","05/04/2020 - was able to find/confirm PTAN through PECOS login - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Omni PPO","Participating","Enrollment Complete","2010-07-14","1881711778","","2020-06-26",""]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","387297379","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","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","","Scott&White (First Care)","Participating","Enrollment Complete","2017-09-14","1881711778","","2020-08-19","8/19/2020 - Rec'd confirmation that this provider is affiliated with the PRIMED DELEGATED ROSTER under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Scott&White (First Care)","Participating","Enrollment Complete","2021-08-02","1881711778","","2022-02-23","2/23/2022 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from August has been completed and provider is PAR effective 8/2/2021.  DCannon"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","United Health Care","Participating","Enrollment Complete","2014-07-01","1124350442","","2020-07-30","07/30/2020 - Rec'd email confirmation from the payer that this provider is effective at this service location and linked with this TIN - Stacey Hudak"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2014-08-08","1124350442","","2020-04-16","04/16/2020 - Rec'd email from the payer with a spreadsheet confirming this provider is effective with ALL PRODUCTS under a PRIMED DELEGATED contract - Stacey Hudak\n\n**verified with payer that the provider is networked with: \nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2018-04-13","1487837712","","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",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2012-02-23","1487837712","","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",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",40354,"","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2016-07-08","1437402278","","2020-06-25",""]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2022-09-01","","","2022-12-29","12/29/2022 Rcvd email from Superior Delegation that August delegation roster has been completed and providers are loaded under appropriate group TIN/locations effective 9/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-07-01","1262269","","2022-08-23","8.23.2022 - Per follow-up note:  S/w Mel of Cigna @ 8008824462, NPI# for the provider is on file, shows link and Par under the TIN# effective 7/1/2022, the physical location is on file and the Provider ID is  1262269. DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-27","9/27/2022 Rcvd email from SuperiorDelegation that July delegation roster has been completed and providers are loaded under appropriate group TIN/locations effective 9/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1437402278","","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",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","Wellcare","Participating","Enrollment Complete",44805,"","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","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"]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","","Amerigroup","In Process","Application Submitted","2024-06-07","","","2024-06-18","Submitted via delegated roster on 6/14/2024. FC"]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","PE - Delight Pediatrics","USA PPO","Provider Load","Provider Load","2024-06-07","","","2024-06-07","new group"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-12-01","","","2022-11-28","11/28/2022 Received email confirmation from Cigna that provider is PAR and linked to group TIN/location effective 12/1/2022.  PID # 9884987.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","Cigna","Participating","Enrollment Complete","2022-12-01","","","2022-11-28","11/28/2022 Received email confirmation from Cigna that provider is PAR and linked to group TIN/location effective 12/1/2022.  PID # 9884987.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2022-10-10","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for October has been completed.  Provider is PAR and linked to group TIN effective 10/10/2022.   DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","PE - Delight Pediatrics","Medicaid","Provider Load","Provider Load","2024-06-07","","","2024-06-07","new group"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","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,"92-0675116","TX","","Multiplan","Provider Load","Provider Load","2024-06-07","","","2024-06-07","new group"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2022-12-01","1013320050","","2023-01-11","1/11/2023 Rcvd TMHP portal provider is PAR and linked to group/ location effective 12/1/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","","TriCare Standard","Provider Load","Provider Load",45450,"","","2024-06-07","new group"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","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"]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","PE - Delight Pediatrics","BCBSTX","Provider Load","Provider Load","2024-06-07","","","2024-06-07","new group"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","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"]
["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","Omni PPO","Participating","Enrollment Complete","2016-10-05","1619008141","","2020-06-25",""]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44286,"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","Medicaid","Participating","Enrollment Complete","","361391101","079837301","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"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Boon Chapman","Enrollment Stopped","Enrollment Stopped","","","","2023-10-16","10/16/2023 Provider is not enrolled in Multiplan, therefore, provider is not enrolled in Boon Chapman.  DCannon"]
["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 Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","CAQH","Participating","CAQH Reattested","2024-06-10","","","2024-06-10","06/10/2024 CAQH Reattested updated and uploaded board wthompson"]
["Leela Sharath 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 Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2021-04-17","1S4718","1S4719","2022-05-03","5/3/2022 Rcvd email from Candace with confirmation of group and provider's individual Medicare PTANS.  Group PTAN # 1S4719 and Individual PTAN # 1S4718 - effective 4/17/2021. \nDCannon"]
["Leela Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Application Resubmitted","2022-01-10","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Leela Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","","","2024-03-28","Per TMHP Dr. PIllarisetty is active at 4911 Andrews Hwy effective 03/28/2024 and active at 421 N Tom Green effective 03/05/2024. Jen Videan"]
["Leela Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Amerigroup","Participating","Application Resubmitted","2022-01-10","12802966","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Leela Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","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 Sharath 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"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1871782961","","2020-07-27","IMS approved"]
["Kavitha Bagadi, MD",1871782961,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete",42370,"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","Superior","Participating","Enrollment Complete","2020-08-01","1871782961","","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"]
["Kavitha Bagadi, MD",1871782961,"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"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Pending Info/Document","2024-06-07","","","2024-06-12","Emailed forms back to Priscilla for completion by provider. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-06-01","6S4368","423838","2024-06-17","Received welcome letter. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","2024-06-07","","","2024-06-12","Please see status updates under Alliance WC payor line. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","2024-06-07","","","2024-06-12","Please see status updates under Alliance WC payor line. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-06-01","1073686","","2024-06-10","This is a facility contract, so midlevels will bill services under the group instead of individual. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-10","Pending Medicare approval. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-06-10","Pending Medicare approval. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Pending Info/Document","2024-06-07","","","2024-06-12","Emailed Sedgwick forms to Priscilla for provider to complete. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-10","Group contract is being decided on. If they want to contract with this TIN, they will request a roster. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-10","Group contract is being decided on. If they want to contract with this TIN, they will request a roster. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted",45450,"","",45455,"Application submitted via pswca.org. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2024-06-20","","","2024-06-20","06/20/2024 CAQH Reattested updated billing and payment address termed one location wthompson"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","2024-06-07","","","2024-06-12","Emailed roster to brandhi_wilson-woods@corvel.com. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","2024-06-07","","","2024-06-12","Emailed roster to brandhi_wilson-woods@corvel.com. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-06-12","1285175927","","2024-06-12","Per updates@primehealthservices.com,  Effective 06/12/2024, Henry Sirengo is now enrolled with Tax ID: 47-3465832. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-06-10","Application submitted for 5 locations. Yukon is on hold. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment on Hold","","","","2024-06-10","Yukon location is on hold until the group app has been updated. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment on Hold","","","","2024-06-10","Yukon location is on hold until the group app has been updated. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-10","Panel is closed to new enrollments. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-06-10","Panel is closed to new enrollments. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","2024-06-18","Application still pending per portal. PA."]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2019-02-01","1053601344","","2020-10-02","10/02/2020- moved to the completed status after reviewing follow up note - Stacey Hudak"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2019-05-31","1053601344","","2020-06-10","06/10/2020 - rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete","2019-02-28","1972816189","","2020-06-29","06/29/2020 - confirmed IMS is par - therefore this enrollment is also effective - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","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."]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2018-08-29","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Cigna","Participating","Enrollment Complete","2019-06-04","1972816189","","2020-08-26","08/26/2020 - moved to completed status after reviewing followup complete note - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Cigna","Participating","Enrollment Complete","2019-06-04","1972816189","","2020-08-26","08/26/2020 - moved to completed status after reviewing followup complete note - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","Medicaid","Participating","Enrollment Complete","","381744701","356723201","2024-01-01","Per TMHP, provider is enrolled and license has been updated. Jen Videan"]
["Chelsea N Luebke, APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-05-31","","","2024-05-31","05/31/2024 CAQH Reattested updated and uploaded DEA wthompson"]
["Chelsea N Luebke, APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete","2018-01-01","5396301","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Chelsea N Luebke, APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2018-05-29","1427452945","","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"]
["Chelsea N Luebke, APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-05-06","Emailed brandhi_wilson-woods@corvel.com for status on last name change. Jen Videan"]
["Chelsea N Luebke, APRN-FNP-BC",1427452945,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete","2021-04-27","1427452945","","2024-05-07","Provider active with Corvel. Jen Videan"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Galaxy Health","Participating","Enrollment Complete","2022-06-01","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for May is complete and provider is loaded effective 6/1/2022.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","Broadspire Services Inc.","In Process","Pending Contracting","","","","2024-04-23","See Broadspire under group record for updates. Jen Videan"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-11-09","","","2023-11-03","11/3/2023 Per email received from Scott & White provider is PAR and linked to group effective 11/9/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2018-07-24","1760860720","","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 Hunter Atkins, MD",1760860720,"84-2617748","TX","PE - Midland Medicine PA","United Health Care","Participating","Enrollment Complete","2022-06-01","006780333","","2022-06-29","6/29/2022 Per email received from  from UHC monthly delegated roster submission has been completed and provider is PAR and in linked to group TIN effective 6/1/2022.   MPIN# 006780333.   DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2023-11-01","","","2023-11-09","11/9/2023 Rcvd email confirmation from Jessica Bess at Multiplan that October roster has been processed and provider is PAR w/ group effective 11/1/2023.  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,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2023-11-01","","","2023-10-19","10/19/2023 Rcvd email  confirmation from Caprock that provider is PAR and linked to group TIN/locations effective 11/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-08-01","P02179382","DW7662","2020-05-04","05/04/2020 -verified and moved to completed status - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-11-01","","","2024-03-19","Welcome ltr rcvd. Provider effective 11/01/2023. Jen Videan"]
["Amber J White, PA",1255614970,"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"]
["Amber J White, PA",1255614970,"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"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1255614970","","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","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","Boon Chapman","Participating","Enrollment Complete","2020-06-03","","","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 6/3/2020.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Humana","Participating","Payor Follow Up","","","","2024-05-15","received email confirmation from Marcus Wester, application and location linked. PA. Pending eff. date. PA."]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","BCBSTX","In Process","Payor Follow Up","","","","2024-05-31","Sent follow up email to Angelica Johnson regarding previous request. PA."]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","BCBSTX","In Process","Payor Follow Up","","","","2024-05-31","Sent follow up email to Angelica Johnson regarding previous request. PA."]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","Caprock (CapStar)","Participating","Payor Follow Up","2024-01-01","","","2024-03-05","03/05/2024 - per email received from Mary Rodgriguez (mary.rodriguez@90degreebenefits.com) location has been added, eff. 1/1/2024. PA."]
["Indira Donepudi, MD",1447406137,"81-1031742","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","TX","PE - Permian Digestive Disease Center PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2024-01-10",""]
["Indira Donepudi, MD",1447406137,"81-1031742","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","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","TX","","Aetna","Participating","Enrollment Complete","2019-09-01","1447406137","","2020-09-22","09/22/2020 - Rec'd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","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","TX","PE - Permian Digestive Disease Center PA","Rail Road Medicare","In Process","Enrollment Complete","2016-01-09","P01708900","DW5495","2024-03-06","Provider is enrolled. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Thru Other Payor","Payor Follow Up","","","","2024-06-21","Sent email requesting group roster from UHC. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Travelers WC","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-01","","","2024-03-08","Rcvd approval letter. Provider effective 03/01/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-03-01","","","2024-03-08","Rcvd approval letter. Provider effective 03/01/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Provider Load","Provider Load","2024-05-29","","","2024-05-29","new location"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-01-18","WTUC has an ancillary contract where midlevel services are billed under the group contract. Individual enrollment isn't required. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Payor Follow Up","","","","2024-06-03","Resubmitted application via email to Allison Provence, per request, as provider is still non-par. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-05-21","","","","Approval ltr rcvd. Effective 05/21/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-05-21","","","","Approval ltr rcvd. Effective 05/21/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-02-05","","","2024-04-05","3/21/2024 - received email confirmation from Karen Avalos (kavalos@ghn-mci.com) Feb. roster completed. Provider is now PAR, eff. 02/05/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-06-18","Group enrollment has been submitted. If the payor wants to contract, they will reach back out and request a roster. There is no follow up needed. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-03-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 03/01/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024 for First Health. FC."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-05-29","","","2024-05-29","05/29/2024 CAQH Reattested added one location wthompson"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Pending Other Enrollment","2024-05-29","","","2024-06-03","Please see status updates under group record payor line. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-03-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 03/01/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-03-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 03/01/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-21","1972506442","","2024-05-22","Approval ltr rcvd. Effective 05/21/2024. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-02-20","2/20/2024 Pending Multiplan enrollment. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-02-01","Q00681843","DX4335","2024-03-06","Provider is linked. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-02-05","","","2024-05-17","Received email confirmation from Marina Martinez (marina.martinez@usamco.com) provider is PAR, eff. 02/05/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-02-01","6H8501","","2024-01-31","Received approval letter eff 2/1/2024. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Pending Other Enrollment","2024-05-29","","","2024-06-18","Please see status updates under group record payor line. Jen Videan"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-05","","","2024-05-20","5/20/2024- Spoke to Audrey call ref #6192822735 all locations  participating as of 2/5/2024. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-06-21","Sent email to payor requesting group roster. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-04-05","Sent email to payor (mwester@humana.com) requesting update on enrollment status. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Application Submitted","","","","2024-06-15","Submitted location add via delegated roster on 6/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Delegated","Add to Next Delegated Roster","","","","2024-01-30","Provider is not showing on Coventry portal, please add to next roster submission. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Thru Other Payor","Application Submitted","","","","2024-06-19","Submitted location add via delegated roster on 6/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-01-18","Per the payor's site, the enrollment for Prime is still closed. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","Provider participating as of 2/5/2024 received via email from Kodi Kox. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-02-07","Received confirmation provider is loaded at all 5 locations. MS"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Rail Road Medicare","Participating","Enrollment Complete","2014-06-10","P02417404","DO2096","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up complete note and downloading EFF letter - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","IMS","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Multiplan","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","USA PPO","Participating","Enrollment Complete","2021-01-26","1312309","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Cigna","Participating","Enrollment Complete","2020-09-15","5009460","","2020-09-18","09/18/2020 - Your effective date is 09/15/2020. Your provider identification number is 5009460.  - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2020-04-03","","","2022-02-26","2/26/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/3/2020.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records immediately upon receipt. KFrazier"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Medicare","Participating","Enrollment Complete","2014-06-10","363200ZH9T","00Y323","2020-03-10","03/10/2020 - Confimed through PECOS that this provider is linked to the corect group and EFF 6-10-2014 - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","United Health Care","Participating","Enrollment Complete","2019-12-01","1750794749","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","CAQH","Participating","CAQH Reattested","2024-06-10","12740460","","2024-06-10","06/10/2024 CAQH Reattested all locations current. Updated and uploaded COI wthompson"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete","2020-08-01","3524170","","2022-04-05","4/5/2022  Per First Health online provider directory provider is PAR and linked to group/locations  effective 8/1/2020.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Omni PPO","Participating","Enrollment Complete","2019-09-01","1750794749","","2020-07-27","IMS completed"]
["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","Galaxy Health","Participating","Enrollment Complete","2020-05-15","1710180666","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","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","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","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","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","CAQH","Participating","CAQH Reattested","2024-06-10","11714128","","2024-06-10","06/10/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-05-01","1447406137","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed note - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2016-08-24","372879ZV0W","519061","2020-04-20","04/20/2020 - Group PECOS enrollment confirrmed this group is listed as provider employer - Stacey Hudak"]
["Jaya Krishna Chadalavada, MD",1710180666,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","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","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","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","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13",""]
["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","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","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","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","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","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","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","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","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","Caprock (CapStar)","Participating","Enrollment Complete","2015-11-01","","","2020-09-14",""]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2015-11-01","","","2020-09-14",""]
["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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","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","HealthSmart PPO","Participating","Application Resubmitted","2019-06-12","13681723","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["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","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","Aetna","Active","Application Resubmitted","2020-10-15","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Application Resubmitted","2019-08-07","1659728855","52669: West Texas Physicians Alliance Group Cntrct","2024-06-24","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Application Resubmitted","2019-06-14","1659728855","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["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","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","Amerigroup","Participating","Application Resubmitted","2019-10-21","1659728855","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["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","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","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","Medicaid","Participating","Enrollment Complete","2023-02-02","","","2024-02-12","Rcvd revalidation approval ltr. Provider effective 02/02/2023. Jen Videan"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Application Resubmitted","2019-06-01","3278559","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["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","Pending Info/Document","2024-04-09","14428752","","2024-06-10","missing correct username and password"]
["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","Omni PPO","Participating","Application Resubmitted","2019-06-14","1659728855","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2021-01-08","","","2024-01-25","During the Tricare audit, it was found this provider is credentialed and is in network with Tricare. MS"]
["Casey Mraz, MD",1659728855,"75-2656723","TX","PE - Premier Family Care, Inc","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",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","Caprock (CapStar)","Participating","Application Resubmitted","2019-06-12","1659728855","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["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"]
["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","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","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","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","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","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","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","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","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","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","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","Scott&White (First Care)","Participating","Enrollment Complete","2019-08-09","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-07","1297078","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2021-01-07","","","2021-02-02","2/2/2021 Rcvd confirmation email from German Aviles that providers have been loaded according to the monthly delegation roster.  DCannon"]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Ali R Khan, MD",1760714380,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","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","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","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","Galaxy Health","Participating","Enrollment Complete","2020-03-24","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 03/24/2020.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Boon Chapman","Participating","Enrollment Complete","2022-04-11","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2022-04-11","","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 4/11/2022. DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-01-19","Received confirmation of approval. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-03","","","2024-02-13","Re-Cred has been completed. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-04-11","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-04-08","The taxonomy code for Dr. Rajasekar has been updated. However, I was given an effective date of 03/22/2024 instead of 06/11/2022 as requested. Upon calling TMHP, I was not given a clear answer on if this will be an issue, so I am having it escalated (Ticket# 48490724000). It can take up to 30 days for a response. In the meantime, MQA if you could ask the office to rebill the claims that they were originally having problems and let us know the outcome (accepted or denied). Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","Pending Info/Document","2024-04-12","","","2024-04-12","current username and password is invalid wthompson"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","CAQH","Participating","Pending Info/Document","2024-04-12","","","2024-04-12","current username and password is invalid wthompson"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","CAQH","Participating","Pending Info/Document","2024-04-12","","","2024-04-12","current username and password is invalid wthompson"]
["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","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","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","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","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","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","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","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Tricare Prime","Participating","Enrollment Complete","2024-01-03","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Aetna","Participating","Enrollment Complete","2022-11-01","6655255","","2022-10-18","10/18/2022 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/1/2022.  PID # 6655255.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete","2022-04-11","","","2022-06-01","6/1/2022 Per Karen Avalos at Galaxy Health April monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  4/11/2022.  DCannon"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","PE - Premier Family Care, Inc","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","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"]
["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","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"]
["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,"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","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","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-04-15","421 N TOM GREEN AVE, ODESSA, TX, 79761 has been added effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicaid","Participating","Enrollment Complete","","1265872592","","2024-06-13","4911 Andrews Hwy Midland TX effective 11/07/2023. Jen Videan"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Medicare","Participating","Enrollment Complete","2023-11-07","6G9855","1S4719","2024-01-17","Received welcome letter eff 11/7/23. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Deepika Devalla, MD",1265872592,"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","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","Galaxy Health","Participating","Enrollment Complete","2020-03-20","1265872592","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-09-27","1265872592","","2020-03-03","03/03/2020 - This provider is linked to this group and service location, however, this group/provider is NON NETWORK. This payer is not currently open to accepting new groups/providers in network.  - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-09-23","09/23/2020 - rec'd confirmation from the payer that this August 2020 roster was completed. This provider/service location was added to PriMed Agreement - OK to move to completed status. - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Boon Chapman","Participating","Enrollment Complete","2022-01-01","","","2004-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2018-03-08","6290221","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","TriCare Standard","Participating","Enrollment Complete","2022-04-18","","","2022-05-06","5/6/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/18/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","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","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-04-13",""]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","HealthSmart PPO","Participating","Enrollment Complete","2022-01-01","","","2022-06-10","6/10/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/1/2022.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2019-09-01","1265872592","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-06-10","13885700","","2024-06-10","06/10/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["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","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,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","In Process","Application Resubmitted","","","","2023-10-20","10/20/2023 Per action needed note 2nd app resubmitted online via Aetna web portal.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-01-23","P02003362","DW7662","2020-05-04","05/04/2020 - Verified and updated payer line - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2016-10-05","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 10/5/2016.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-02-15","1265872592","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 2-15-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Rail Road Medicare","Participating","Enrollment Complete","2023-11-07","P02729129","ED2193","2024-03-06","Provider is linked. MS"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Aetna","Participating","Enrollment Complete","2022-01-01","5484622","","2022-06-21","6/21/2022 Per follow-up note - 06/13/2022 - S/w Chris of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 01/01/2022 under the group and TIN#. PIN: 5484822. Physical location is on file. Call ref# 6095008958. - DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","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,"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,"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,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","USA PPO","Participating","Enrollment Complete","2022-01-01","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 1/1/2022.  Provider is also listed on the online provider directory.  DCannon"]
["Deepika Devalla, MD",1265872592,"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","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","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2023-09-18","","","2023-10-02","10/2/2023 Rcvd email confirmation from Scott & White that provider is PAR and linked to group/locations effective 9/18/2023.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1238661","","2021-01-01","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","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,"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,"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,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1265872592","","2020-11-02","11/2/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2016-11-17","P01787070","DW7662","2020-05-04","05/04/2020 - verified and moved to effective status - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Re-Credentialing","2016-12-15","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Provider Load","CAQH Reattested","2024-06-03","","","2024-06-03","06/03/2024 CAQH Reattested all locations current and all expirables up to date wthompson"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1649713595","","2020-07-27","IMS  complete"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2018-05-29","1649713595","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 5-29-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1649713595","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Re-Credentialing","2020-09-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2016-12-15","1649713595","","2020-04-30","04/30/2020 - confirmed this provider/service location are linked to TIN through payer portal - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","Participating","Enrollment Complete","2020-01-01","1649713595","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","1312372","","2021-03-13","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-10-01","1649713595","","2020-10-02","10/02/2020 - Rec'd email from the payer stating this provider has been added to the primed roster - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Re-Credentialing","2020-03-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2016-11-17","1649713595","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2021-03-01","367256001","364596201","2021-03-01","3/1/2021 Received nofication TMHP revalidation has been completed successfully and provider is due for revalidation 2/25/2026. KFrazier"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Re-Credentialing","2019-09-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Re-Credentialing","2020-04-03","","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-04-03","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 4/3/2020.   DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Re-Credentialing","2017-02-23","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-03-12","1649713595","","2020-08-31","08/31/2020 - moved to completed status after reviewing follow up completed status - Stacey Hudak"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing","2020-08-01","1649713595","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Jeremiah L Stewart, APRN-FNP-BC",1649713595,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","Galaxy Health","Participating","Enrollment Complete","2020-04-03","1013456649","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","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","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","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","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","Medicaid","Participating","Enrollment Complete","2017-05-17","372790101","364596201","2024-05-08","Rcvd approval ltr. Jen Videan"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","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","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","Amerigroup","Participating","Enrollment Complete","2018-04-20","1013456649","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) confirming that this provider is EFF with Amerigroup at this serivce location. - Stacey Hudak"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","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","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"]
["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","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","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","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","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","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","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","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"]
["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"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2018-06-19","1497985188","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Vikram R Vadyala, MD",1497985188,"47-1394805","TX","PE - Vikram Vadyala, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-25","1497985188","","2020-08-20","8/20/2020 - Rec'd spreadsheet from the payer stating this provider has been affiliated with PRIMED DELEGATED AGREEMENT under this TIN/Service Location. Provider is networked with:\nFirstCare MyChoice PPO\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]

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

{"sheet":"NPISearch","index":3,"n_rows":23,"n_cols":11,"rows_kept":23,"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","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","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","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","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","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","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"]
["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"]