| Northeast Texas Neurology Associates, P.a. | |
|
505 S Fleishel Ave Tyler TX 75702-8413 | |
| (903) 526-7055 | |
| (903) 593-4303 |
| Full Name | Northeast Texas Neurology Associates, P.a. |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 505 S Fleishel Ave, Tyler, Texas |
| Authorized Official Name and Position | Gina M. Jetter (PRESIDENT) |
| Authorized Official Contact | 9035267055 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Northeast Texas Neurology Associates, P.a. 505 S Fleishel Ave Ste 800 Tyler TX 75702-8413 Ph: (903) 526-7055 | Northeast Texas Neurology Associates, P.a. 505 S Fleishel Ave Tyler TX 75702-8413 Ph: (903) 526-7055 |
| NPI Number | 1972680130 |
|---|---|
| Provider Enumeration Date | 11/01/2006 |
| Last Update Date | 08/16/2022 |
| Certification Date | 08/16/2022 |
| Medicare PECOS PAC ID | 7719012913 |
|---|---|
| Medicare Enrollment ID | O20100312000561 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1972680130 | NPI | - | NPPES |
| 115025205 | Medicaid | TX | |
| 143629701 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084N0400X | Psychiatry & Neurology - Neurology | E6235 (Texas) | Primary |
| Provider Name | Gina M Jetter |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1346422532 PECOS PAC ID: 3577732817 Enrollment ID: I20110803000302 |
| Provider Name | Fraquania Talesh Freeman |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1821499682 PECOS PAC ID: 0143441725 Enrollment ID: I20141023001924 |
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