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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",45656,"11483093","","2024-12-30","12/30/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Active","CAQH Reattested","2024-11-20","14145595","","2024-11-20","11/20/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Lori Ann Brown, 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 Brown, APRN-FNP-BC",1023520830,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2020-06-29","1023520830","","2020-07-09","07/09/2020 - Rec'd welcome letter from Multiplan stating provider is covered for all governmental payers - Amerigroup is covered (STAR, Star Plus, Star Kids) - Stacey Hudak"]
["Lori Ann Brown, APRN-FNP-BC",1023520830,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2020-06-29","1023520830","","2024-07-22","Submitted designation role to PCP in July roster via delegated roster. FC"]
["Lori Ann Brown, APRN-FNP-BC",1023520830,"75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2020-06-29","1023520830","","2024-07-22","Submitted designation role to PCP in July roster via delegated roster. FC"]
["Lori Ann Brown, 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 Brown, 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 Brown, 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 Brown, 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 Brown, 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"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2019-08-01","","","2024-08-15","Provider is already enrolled and linked to group effective 08/01/2018. Jen Videan"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-08-01","703171","519061","2024-08-15","Provider was already enrolled and linked to this TIN. MS"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2024-07-01","0044767","","2024-08-23","Provider has been linked and is active under this TIN. MS"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Participating","Enrollment Complete","2018-08-01","P02179380","DW7662","2024-08-15","Provider enrolled and active. MS"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2018-07-17","","","2024-08-15","Provider is active and linked to location. MS"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-08-13","location is not tricare credentialed, and the panel is currently closed. MS"]
["Angel A Tejada Mejia, MD",1982085205,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-11-04","","","2024-11-04","11/04/2024 CAQH Reattest Profile updated pklika"]
["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",43270,"","","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",45610,"14218808","","2024-11-14","11/14/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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",43325,"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",43312,"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",42995,"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",45236,"","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","Caprock (CapStar)","Participating","Enrollment Complete",45236,"","","2023-12-28","12/28/2023 Per email received from Caprock December delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted",45236,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted",45236,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","BCBSTX","Participating","Enrollment Complete","2024-04-09","","","2024-04-08","Received email provider is now PAR and participating with the following networks, eff. 4/9/2024:\nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nMCH - Medicare Advantage HMO\nSNP - Dual Eligible Special Needs Plan\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO\nWEL - WellMed MA HMO. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","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","2023-10-09","","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 10/09/2023 and linked to 400 Rosalind Redfern, Suite 230. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete",45208,"","","2024-02-29","Per roster received from Aleece Moerbe (Aleece.Moerbe@healthsmart.com) on 02/23/2024, provider is PAR, eff. 10/09/2023 and linked to 400 Rosalind Redfern, Suite 230. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted","2023-10-09","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","HealthSmart PPO","Participating","Add Info Submitted",45208,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","USA PPO","In Process","Payor Follow Up","","","","2024-07-30","Sent email to payor requesting enrollment status update. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",45236,"","","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,"75-2656723","TX","","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,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Humana","Participating","Enrollment Complete",45208,"","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","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","Payor Follow Up","","","","2024-07-08","Sent email to payor requesting status update. 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",45328,"","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","IMS","Participating","Enrollment Complete",45328,"","","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","IMS","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","IMS","Participating","Add Info Submitted",45328,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",45292,"","","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","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",45292,"","","2024-08-09","Received notification via email Dr. Ammu par as of 1/1/2024. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Multiplan","Participating","Enrollment Complete",45328,"","","2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Multiplan","Participating","Enrollment Complete",45328,"","","2024-07-11","7/11/2024 As per Marcie Eckhart provider participating as of 2/6/2024. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Multiplan","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Multiplan","Participating","Add Info Submitted",45328,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Ambetter","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","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,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted",45236,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-01-02","","","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",45328,"","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Omni PPO","Participating","Enrollment Complete","2024-02-06","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/6/2024 received via email. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Omni PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Omni PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Galaxy Health","Participating","Enrollment Complete","2024-02-06","","","2024-04-16","Received email from Karen Avalos confirming roster completed; provider is PAR under TIN: 75-6000608, eff. 2/06/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-11-06","","","2024-02-15","Per phone call, the provider is linked to TIN eff 11/6/2023. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-21","","","2024-11-21","11/21/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","Participating","Enrollment Complete","2024-02-01","0446524","","2024-09-05","Received confirmation email. MS"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-11-01","","","2023-12-19","Rcvd TMHP Welcome letter. Provider effective 11/01/2023. Jen Videan"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","HealthSmart PPO","Participating","Enrollment Complete","2024-02-06","","","2024-07-04","7/4/2024 provider participating as of 2/6/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","HealthSmart PPO","Participating","Enrollment Complete","2024-02-06","","","2024-07-04","7/4/2024 provider participating as of 2/6/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","HealthSmart PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","HealthSmart PPO","Participating","Add Info Submitted","2024-02-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted",45236,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2023-11-06","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","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","Participating","Enrollment Complete","2024-09-03","","","2024-10-25","Welcome ltr rcvd. Effective 09/03/2024. Jen Videan"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-06","00920011605","","2024-01-29","1/29/2024 Per UHC provider portal provider is PAR and linked to group TIN/locations effective 11/6/2023. MPIN # 00920011605.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","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,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2023-10-09","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","United Health Care","Participating","Enrollment Complete","2024-02-06","","","2024-11-19","Received product roster from UHC. Provider is listed PAR, linked to TIN & location, eff. 2/6/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Amerigroup","In Process","Add Info Submitted","","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","PPHP","Participating","Enrollment Complete",45407,"","","2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","First Health Coventry","Participating","Enrollment Complete",45383,"","","2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","First Health Coventry","Participating","Enrollment Complete",45383,"","","2024-07-17","As per Ashanti call ref#1130732, provider participating as of 4/1/2024, listed as a SPEC. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","First Health Coventry","Participating","Add Info Submitted",45383,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","First Health Coventry","Participating","Add Info Submitted",45383,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-06","008925217","","2024-01-23","1/23/2024  Rcvd confirmation email from UHC that provider is PAR and linked to group TIN/location effective 11/6/2023.  MPIN # 008925217.  DCannon"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20","","","2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-20","","","2024-06-07","Received confirmation via email  from Mary mary.rodriguez@90degreebenefit.com provider participating as of 10/9/2023. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-10-20","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Superior","Participating","Enrollment Complete","2024-04-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff.  04/01/2024. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",45208,"","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 10/09/2023. PA"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","PPHP","Participating","Enrollment Complete","2024-04-25","","","2024-07-12","Received email confirmation from PPHP,  provider is PAR and linked to TIN/location, eff. 04/25/2024.  PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-11-01","6C4889","","2023-11-28","Provider is already enrolled with this group and locations. MS"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","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","","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","Aetna","Participating","Payor Follow Up","2024-02-06","","","2024-07-17","As per Dennis R call ref#6198039875, suite number is not tied to TIN. I will fax a letter of intent to 859-455-8650 for demographic update to add suite 22. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","","Aetna","Participating","Payor Follow Up","2024-02-06","","","2024-07-17","As per Dennis R call ref#6198039875, suite number is not tied to TIN. I will fax a letter of intent to 859-455-8650 for demographic update to add suite 22. FC"]
["Anusha Ammu, MD",1386135713,"75-6000608","TX","PE - City of Midland Health Department","Triwest VA","Thru Other Payor","Payor Follow Up","","","","2024-08-19","Requested status update on enrollment via email to Scarlett Abigail. PA."]
["Anusha Ammu, MD",1386135713,"75-2656723","TX","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","2023-11-06","","","2024-04-11","4/11/2024 As per Cassandra (WellPoint rep) Dr. Bennion is par effective 11/6/2023. FC"]
["Glen Allen Bennion, DO",1386132876,"83-0358685","TX","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"]
["Bethany M Lucas, 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 Lucas, 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 Lucas, 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 Lucas, 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 Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Thru Other Payor","2023-05-25","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","","Zurich","Participating","Thru Other Payor","2023-05-25","","","2024-01-26","Not listed on Coventry portal. Please add to next delegated submission. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete",45071,"","","2024-09-13","9/13/2024 As per John (call ref#18150839) provider participating as of 5/25/2023. FC"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","","Zurich","Participating","Enrollment Complete",45071,"","","2024-09-13","9/13/2024 As per John (call ref#18150839) provider participating as of 5/25/2023. FC"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","Participating","Re-Credentialing",45030,"","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete",45065,"","","2023-07-18","Michelle Killough confirmed provider is effective 5/19/2023. MS See Alliance for enrollment note updates."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete",45462,"1225283963","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Amerigroup","Participating","Re-Credentialing",45030,"","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","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 Lucas, 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 Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Broadspire Services Inc.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Bethany M Lucas, 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 Lucas, 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 Lucas, 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 Lucas, 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 Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","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 Lucas, 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 Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-05-01","","","2023-08-21","Received confirmation. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2023-05-19","","","2023-05-22","Michelle Killough confirmed provider is effective 5/19/2023. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete",45047,"2T0202","","2023-05-10","5/10/2023 Rcvd Medicare approval letter.  PTAN # 2T0202 - effective 5/1/2023.   DCannon"]
["Bethany M Lucas, 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 Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","CAQH","Participating","CAQH Reattested","2024-12-04","","","2024-12-04","12/04/2024 new COI uploaded pklika"]
["Bethany M Lucas, 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 Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete",45139,"","","2023-08-08","Rcvd approval letter. Effective 08/01/2023. Jen Videan"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","United Health Care","Participating","Enrollment Complete",45047,"003614004","","2023-11-15","11/15/2023 Per email received from UHC provider is PAR and linked to group TIN effective 5/1/2023.  MPIN# 003614004.  DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete",45041,"","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Multiplan","Participating","Re-Credentialing",45030,"","","2024-04-15","4/17/2024- Submitted recred status via delegated monthly roster on 4/15/2024. FC."]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Payor Follow Up",45030,"","","2024-05-16","5/16/2024 Payor has incorrect address, updated address submitted via delegated roster on 5/15/2024. FC"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete",45030,"","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from April has been completed and provider is PAR effective 4/14/2023.  DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2023-05-01","","","2024-07-25","Revalidation approval ltr rcvd. Effective 05/01/2023. Jen Videan"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellcare","Participating","Enrollment Complete",45047,"","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Ambetter","Participating","Enrollment Complete",45047,"","","2023-07-25","7/25/2023 Rcvd confirmation email from Superior that April delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 5/1/2023.  DCannon"]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","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 Lucas, 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 Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Triwest VA","In House Enrollment","In House Enrollment","","","","2023-04-18",""]
["Bethany M Lucas, PA",1225283963,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27",""]
["Bethany M Lucas, 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 Lucas, 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 Lucas, 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","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","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",44713,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete",43312,"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","Medicare","Participating","Enrollment Complete","","","","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","","Medicare","Participating","Enrollment Complete","","","","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Pending Info/Document","","","","2025-01-03","Pending surrogacy . MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","","Medicare","Participating","Pending Info/Document","","","","2025-01-03","Pending surrogacy . MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","In Process","Confirm Par Status","","","","2024-09-11","Emailed Kathryn.schiewe@zurichna.com for par status. Jen Videan"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","HealthSmart PPO","Participating","Enrollment Complete",43308,"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","Rail Road Medicare","In Process","Pending Info/Document","","","","2024-10-16","Pending MCR information from the group. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-09-09","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","Broadspire Services Inc.","In Process","Confirm Par Status","","","","2024-09-11","Emailed providerrelations@primehealthservices.com and marsha.swader@primehealthservices.com to confirm par status. Jen Videan"]
["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","Sedgwick","Participating","Enrollment Complete","","","","2024-10-08","Per SPNEAST@sedgwickcms.com, provider is already credentialed in their Network. Provider was with CareWorks before Sedgwick acquired them & they do not have access to letters from that time. Jen Videan"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2024-11-19","","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","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",43305,"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","Alliance WC","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2018-12-06","","","2024-09-09","Confirmed provider is linked to this location. MS"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","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",43305,"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",43305,"1740542034","","2020-06-26","06/26/2020 - EFF IF IMS IS EFF - Stacey Hudak"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","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","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-10-01","Supplied Brandhi_Wilson-Woods@Corvel.com with W9 per request, she will forward to nomination panel along with roster and they will make a decision. Jen Videan"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete",43313,"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"]
["Ryan S Rowland, MD",1740542034,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete",43313,"","","2024-09-19","Approval ltr rcvd. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","United Health Care","Participating","Enrollment Complete",43971,"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","Medicare","Participating","Enrollment Complete","","","","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete",44713,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Galaxy Health","Participating","Enrollment Complete",43709,"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","2024-11-19","","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","2020-01-05","412587401","325373401","2024-09-09","Per TMHP provider still showing effective/active and linked 01/05/2020. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","In Process","Confirm Par Status","","","","2024-09-11","Emailed providerrelations@primehealthservices.com and marsha.swader@primehealthservices.com to confirm par status. Jen Videan"]
["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","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","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","Sedgwick","Participating","Enrollment Complete","","","","2024-10-08","Per SPNEAST@sedgwickcms.com, provider is already credentialed in their Network. Provider was with CareWorks before Sedgwick acquired them & they do not have access to letters from that time. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","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",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"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","In Process","Pending Info/Document","","","","2024-10-16","Pending MCR information from the group. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete",44379,"","","2024-09-09","Provider has been confirmed linked to this location. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-09-09","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","IMS","Participating","Enrollment Complete",43709,"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","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-10-01","Supplied Brandhi_Wilson-Woods@Corvel.com with W9 per request, she will forward to nomination panel along with roster and they will make a decision. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","In Process","Confirm Par Status","","","","2024-09-11","Emailed Kathryn.schiewe@zurichna.com for par status. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Aetna","Participating","Enrollment Complete",44075,"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",43957,"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","Alliance WC","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Pamela F Doughty, PA",1346807278,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2024-08-29","Received confirmation from Cassandra Dunagon provider is participating with all products. FC"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","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","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete",43399,"1649462987","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Gautham S Gadiraju, MD",1649462987,"47-5554737","TX","PE - Midland Inpatient Medical Association","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",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"]
["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",43313,"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",43434,"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",43508,"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",43395,"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",43831,"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",43434,"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",44070,"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",45618,"","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","2018-08-01","1407149883","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 8-1-2018 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-06-05","060/5/2020 - Rec'd email from the payer stating this provider is EFF - Stacey HUdak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2018-09-01","377470502","364596201","2023-08-22","Revalidation approval ltr rcvd via TMHP website. Effective 09/01/2018. Jen Videan"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","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",43395,"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","2018-12-01","1407149883","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 12-1-2018 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Vamsi K Korrapati, MD",1407149883,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2018-10-26","1407149883","","2020-02-13","02/13/2020 - Rec'd emailed confirmation from the payer that this provider is EFF and DIRECT CONTRACTED under this TIN - Stacey Hudak"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete",45362,"","","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","HealthSmart PPO","Participating","Enrollment Complete",45362,"","","2024-08-30","Received confirmation via email from Aleece Moerbe provider participating as of 3/11/2024. FC"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete",45362,"","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  03/11/2024.  PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2024-04-15","","","2024-09-04","Roster received from the payor. The provider is listed as PAR, effective  4/15/2024, and is linked to the TIN and location. PA."]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","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","Amerigroup","Participating","Enrollment Complete","2024-03-13","","","2024-08-08","Provider PAR with Star, Star kids, and Star + eff date 3/13/2024 as per roster received from Cassandra via email. FC"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","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","First Health Coventry","Participating","Enrollment Complete","2024-04-01","","","2024-08-08","Provider participating as of 4/1/2024 listed as Pediatrics, spoke to Tash call ref#11607782. FC"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","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","Caprock (CapStar)","Participating","Enrollment Complete","2023-12-28","","","2024-08-16","Received confirmation from Mary Rodriguez via e,mail, provider participating as of 12/28/2023. FC"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","Participating","Enrollment Complete","2024-03-11","","","2024-08-16","Received confirmation from Jessica Bess via email provider participating as of 3/11/2024. FC"]
["Kevin W Benson, MD",1326061086,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2024-03-11","","","2024-08-08","Received confirmation provider is PAR and linked to TIN/location, eff. 3/11/2024. Product roster uploaded. PA."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete",43595,"","","2024-07-24","Approval Ltr rcvd. Effective 05/10/2019. Jen Videan"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Caprock (CapStar)","Participating","Re-Credentialing",43559,"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","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicare","Participating","Enrollment Complete",43525,"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",44562,"","","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",43972,"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",45621,"","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","","","","2024-08-22","Revalidation approval ltr rcvd. Jen Videan"]
["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","Participating","Enrollment Complete","2024-06-19","1588857874","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","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","Texas Municipal League","Participating","Enrollment Complete",43595,"","","2024-07-24","Please see status updates under Alliance WC payor line. Jen Videan"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Zurich","Participating","Enrollment Complete",43616,"","","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",43559,"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","In Process","Application Submitted",43606,"1588857874","","2024-12-18","Per Aetna rep Mary Hanna, provider termed as of 5/28/2024. Resubmitted application (roster) via email to Mary Hanna. PA."]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Liberty Mutual","Participating","Enrollment Complete",43770,"","","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","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","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","2019-05-31","1588857874","","2020-08-19","8/19/2020 - Rec'd spreadsheet from the payer confirming this provider is linked to the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with:\nFirstCare MyChoice PPO\nCHIP\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["John W Mathewson, MD",1588857874,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","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",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."]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1164778767","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","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",45621,"","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","","","","2024-09-10","Please see status updates under Alliance WC payor line. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","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"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-09-04","Emailed Brandhi_Wilson-Woods@Corvel.com for status. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","Participating","Enrollment Complete","2019-05-01","","","2020-08-05","8/5/2020- Per email response received from  Texas Mutual on  8/4/2020, provider NPI# is on file for the provider and is participating effective 5/1/2019 under the group and TIN#. Physical location is on file. - Elonah Grace B. Gelig"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","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",44562,"","","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","Alliance WC","Participating","Enrollment Complete",44883,"","","2024-09-10","Welcome ltr rcvd. Effective 11/18/2022. Jen Videan"]
["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","Aetna","In Process","Payor Follow Up","2024-04-05","","","2025-01-03","Sent email to Mary Hanna requesting status on enrollment. PA."]
["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","2019-05-31","1164778767","463131679","2020-08-18","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete",43622,"","","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.","Participating","Enrollment Complete","2024-01-11","","","2024-07-08","Contract complete. Effective 01/11/2024. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","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","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","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"]
["Kristin L Rettig, PA",1164778767,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Application Submitted","","","","2023-06-19","6/19/2023 Roster submitted."]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Application Submitted","","","","2023-06-19","6/19/2023 Roster submitted."]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Application Submitted","","","","2023-06-19","6/19/2023 Roster submitted."]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","In Process","Application Submitted","","","","2023-06-19","6/19/2023 Roster submitted."]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45617,"13859704","","2024-12-04","12/04/2024 Request location removed, requested location added pklika"]
["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","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","IMS","In Process","Application Submitted","","","","2024-12-11","Submitted via delegated roster. AS"]
["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","Superior","In Process","Application Submitted","","","","2024-12-13","Submitted location add via delegated roster submission. PA."]
["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","Wellcare","In Process","Application Submitted","","","","2024-12-13","Submitted location add via delegated roster submission. PA."]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 01/01/2020. PA."]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","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","Scott&White (First Care)","In Process","Application Submitted","","","","2024-12-13","Submitted location add via delegated roster submission. PA."]
["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","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","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","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","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","Rail Road Medicare","Participating","Enrollment Complete","2019-05-01","P02252784","","2024-12-20","Confirmed providers enrollment. MS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","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","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","Wellmed","In Process","Application Submitted","","","","2024-12-13","Submitted location add via delegated roster submission. PA."]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","In Process","Application Submitted","","","","2024-12-13","Submitted location add via delegated roster submission. PA."]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Sedgwick","Participating","Provider Load","","","","",""]
["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","Caprock (CapStar)","In Process","Application Submitted","","","","2024-12-11","Add location submitted via delegated roster. AS"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","In Process","Application Submitted","","","","2024-12-13","Submitted location add via delegated roster submission. PA."]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","PPHP","In Process","Application Submitted","","","","2024-12-13","Submitted location add via delegated roster submission. PA."]
["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",43586,"","","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","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","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","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","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","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","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","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","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","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","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","","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","Amerigroup","Participating","Application Resubmitted","2019-05-31","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","","Amerigroup","Participating","Application Resubmitted","2019-05-31","1639524861","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","In Process","Application Submitted","","","","2024-12-13","Submitted location add via delegated roster submission. PA."]
["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","United Health Care","In Process","Application Submitted","","","","2024-12-13","Submitted location add via delegated roster submission. PA."]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","In Process","Application Submitted","","","","2024-12-13","Submitted location add via delegated roster submission. PA."]
["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","Omni PPO","In Process","Application Submitted","","","",45637,"Submitted via delegated roster. AS"]
["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"]
["Rachel K Longacre, APRN-FNP-BC",1639524861,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","In Process","Application Submitted","","","","2024-12-11","Submitted via delegated roster. AS"]
["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","","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","Omni PPO","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Omni PPO","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","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","","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","HealthSmart PPO","Participating","Add Info Submitted","2019-09-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","HealthSmart PPO","Participating","Add Info Submitted","2019-09-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Corvel Healthcare Corp.","In Process","Payor Follow Up","","","","2024-10-01","Supplied Brandhi_Wilson-Woods@Corvel.com with W9 per request, she will forward to nomination panel along with roster and they will make a decision. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-09-09","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","","Caprock (CapStar)","Participating","Enrollment Complete","2019-08-26","","","2020-09-14",""]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Add Info Submitted","2019-08-26","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2019-08-26","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Broadspire Services Inc.","In Process","Confirm Par Status","","","","2024-09-11","Emailed providerrelations@primehealthservices.com and marsha.swader@primehealthservices.com to confirm par status. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Enrollment Complete",43709,"842726","270548","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS   Eff 8/2024, Symplr will now manage. MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Medicare","Participating","Enrollment Complete","2019-09-01","842726","270548","2024-09-09","Per the Medicare site, the provider is linked to this group. I do not have an effective date as I do not have surrogacy to this group's PTAN for the Part B.. only the 855S. MS   Eff 8/2024, Symplr will now manage. MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicare","Participating","Pending Info/Document",43709,"842726","270548","2025-01-03","Pending surrogacy . MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Medicare","Participating","Pending Info/Document",43709,"842726","270548","2025-01-03","Pending surrogacy . MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete",43709,"","","2024-07-08","Revalidation approved. Effective 09/01/2019. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Sedgwick","In Process","Confirm Par Status","","","","2024-09-11","Emailed SPNEAST@sedgwickcms.com for par status. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete",44713,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested",45615,"","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","See status updates under Alliance WC payor line. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","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","","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","Multiplan","Participating","Add Info Submitted","2019-09-01","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Multiplan","Participating","Add Info Submitted","2019-09-01","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","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","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","USA PPO","Participating","Enrollment Complete",43707,"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","","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","Amerigroup","Participating","Add Info Submitted","2020-04-15","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","Amerigroup","Participating","Add Info Submitted","2020-04-15","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2019-12-05","","","2024-09-09","Provider is linked to this location. MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","In Process","Confirm Par Status","","","","2024-09-11","Emailed Kathryn.schiewe@zurichna.com for par status. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","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","","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","IMS","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","","IMS","Participating","Add Info Submitted","2019-08-26","1144665233","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Enrollment Complete","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["William Gage Liesman, MD",1144665233,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Rail Road Medicare","Participating","Pending Info/Document","","","","2024-10-16","Pending MCR information from the group. MS"]
["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",45082,"","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-06-05","","","2023-10-19","10/19/2023 Per email received from Jessica Bess at  Multiplan provider is PAR with Amerigroup and linked to group TIN/locations thru Multiplan enrollment effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","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",45621,"13876531","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-25","13876531","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-25","13876531","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-25","13876531","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","","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.","IMS","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","IMS","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","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",43586,"804641","0008AH","2023-07-17","7/17/2023 Per PECOS - Medicare provider is PAR and linked to group/location.  PTAN# 804641.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","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","2019-07-01","5258891","","2023-08-16","8/16/2023 Per follow-up note - provider NPI# is on file for the provider and is participating effective 07/01/19 under the group and TIN#. Location address is on file. PIN# 5258891. DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Rec'd email confirmation from Multiplan/Texas True Chioce stating EFF information is correct - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-02-11","2/11/2020 – Received Roster from Amerigroup and provider is now PAR- Tisha Rader\n\n3/18/2020 - Rec'd email confirmation from Multiplan/Texas True Chioce stating EFF information is correct - Stacey Hudak"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Amerigroup","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2019-07-20","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/20/2019.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","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","","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","Caprock (CapStar)","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","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","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","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","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2023-06-05","","","2023-07-18","7/18/2023 Per email received from IMS/OMNI June delegated roster has been processed and provider is PAR and linked to group effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc.","Omni PPO","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",45082,"","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2023-06-05","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 6/5/2023.  DCannon"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Multiplan","Participating","Add Info Submitted","2023-06-05","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","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","","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","Multiplan","Participating","Add Info Submitted","2019-07-20","1932541406","52669: West Texas Physicians Alliance Group Cntrct","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Multiplan","Participating","Add Info Submitted",43666,"1932541406","52669: West Texas Physicians Alliance Group Cntrct","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","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","","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","Caprock (CapStar)","Participating","Add Info Submitted","2019-06-12","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2019-06-12","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","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",43586,"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","","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","HealthSmart PPO","Participating","Add Info Submitted","2019-06-12","1932541406","","","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","HealthSmart PPO","Participating","Add Info Submitted","2019-06-12","1932541406","","","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","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","2019-09-30","1932541406","","2020-06-25",""]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-30","1932541406","","2020-06-25",""]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Madhavi Gadiraju, MD",1932541406,"75-2656723","TX","","Omni PPO","Participating","Add Info Submitted","2019-09-30","1932541406","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-08-01","1528619525","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Megan Casselman, NP-C",1528619525,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","","","2024-08-21","Revalidation Approval Ltr rcvd. Jen Videan"]
["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","2024-11-21","14530139","","2024-11-21","11/21/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","2024-06-06","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-09-01","","","2022-09-08","9/8/2022 Per roster received from Superior August monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  9/1/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",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",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",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",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","Ambetter","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","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",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","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",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","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","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","",44862,"10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-08-12","","","2022-10-28","10/28/2022 Per follow-up note from 10.21.2022 S/W Gloria of Amerigroup @ 800-454-3730. Per rep, provider is on file and participating. Link under the group and TIN effective 8/12/2022. Location is on file. Provider ID is 14387628. No recredentialing date. Dcannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-08-28","","","2024-06-27","provider is already linked to group record and all locations are confirmed. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete",44801,"","","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",44801,"","","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",44801,"","","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",44801,"","","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",44801,"","","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","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-06-17","","","2024-07-02"," Provider linked to all locations effective 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","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","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","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","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,"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","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","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",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","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-07-01","Locations are already listed in the group record, so the provider is already linked to them.MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45608,"","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45608,"","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested",45608,"","","2024-12-09","12/9/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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",44816,"","","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","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2024-06-17","","","2024-07-02","Provider is Credentialed with all locations eff 6/17/2024. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","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,"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","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,"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","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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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","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",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",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",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",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",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",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",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","Aetna","Participating","Enrollment Complete",45449,"","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45449,"","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45449,"","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45449,"","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45449,"","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45449,"","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45449,"","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45449,"","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45449,"","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",45449,"","","2024-11-20","REF#173759248. Provider is confirmed active under the TIN and linked to all locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","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,"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,"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,"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","Medicaid","Participating","Enrollment Complete",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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",44801,"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","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44785,"","","2024-08-29","Received confirmation from Cassandra Dunagon the remaining address are effective 8/12/2022.  FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Payor Follow Up","","","","2024-09-04","Application in PE Review status. Emailed TMHP PE for update/escalation. Jen Videan"]
["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",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",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",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","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,"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","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",44816,"","","2022-09-15","9/15/2022 Received approval notification from Scott & White that provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete",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","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2024-10-07","Received confirmation via email, provider participating as of 1/1/2020. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","In Process","Application Submitted","","","","2024-12-11","Submitted via delegated roster. AS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",45444,"8909854","","2024-07-03","Received confirmation the provider has been linked to these new locations. MS"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",45453,"","","2024-08-16","Received confirmation from German Aviles via email provider participating for the 3 locations as of 6/10/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","2022-08-11","8/11/2022 Rcvd Medicare approval letter.  Provider is PAR and linked to group/locations -   PTAN # 2G9994 - effective 8/28/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44801,"2G9994","0008AH","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","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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",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",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete",44880,"","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2022-11-15","","","2023-01-23","1.23.23 Rcvd confirmation from Aetna that provider is PAR at the following locations only (709 W Louisiana Ave, 3411 Caldera, 3415 N Loop 250) effective 11/15/2022 Provider ID is 6669419. Link Letter and W9 will need to be submitted by fax @859-455-8650 to Aetna (attn to network management) to link provider to other locations.  TAT is 10-15 business days. ABoles"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",44785,"","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2022-08-12","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2022-09-12","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 9/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",43831,"","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2020-01-01","","","2022-10-12","10/12/2022 Per email from Priscilla Albertine she rcvd confirmation from Mary Rodriguez at Caprock that provider is PAR and linked to group TIN/locations effective 1/1/2020.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete",44785,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-08-12","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/12/2022.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","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","","","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","","","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","","","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","","","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",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","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",44931,"","","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",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","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",44931,"","","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",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","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",44931,"","","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",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","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",44931,"","","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",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","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",44931,"","","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",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","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",44931,"","","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",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","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",44931,"","","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",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","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",44931,"","","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",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44931,"","","2023-01-18","1/18/2023 Rcvd letter from Tricare that provider is now Tricare certified effective 1//5/2023.  DCannon"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-01-05","","","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","","","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","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Venessa R Saldana, APRN-FNP-BC",1922658319,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","7/31/2024 As Per Jessica Bess, 400 Rosalind Redfern Ste 230 eff date 6/6/2024, 4214 Andrews Hwy Ste 102 & 103 eff 6/6/2024, 4507 Santa Rosa eff 6/6/2024. FC"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","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","HealthSmart PPO","Participating","Enrollment Complete","2020-10-13","13747034","","2020-12-23","12/23/2020 - Confirmed with HealthSmart that provider has been loaded effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2020-10-01","403920802","","2024-06-13","Per TMHP license has been updated. Jen Videan"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","1312370","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-10-15","","","2020-11-20","11/20/20 - Rcvd confirmation email from UHC confirming enrollment at this location.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2020-12-24","","","2021-05-09","5/9/2021 Upon review of the self-service portal, provider is participating under group Tax ID and practice location effective 12/24/2020. KFrazier"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-10-01","1J2798","0008AH","2020-11-18","11/18/2020 - Rcvd notification from Novitas that Change of Information app has been approved.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2020-10-01","","","2020-10-09","10/9/2020 Confirmed provider is certified as a non-network provider with TriCare East. Kimberly Frazier"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-02-09","1299432","","2021-02-20","2/20/2021 - Rcvd email from Cigna that provider has been approved effective 2/09/2021 PIN # 1299432.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"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."]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2021-03-12","","","2021-03-18","3/18/2021 Received email from BSWHPEXPEDITES@BSWHealth.org confirming provider has been approved and is participating under group effective 3/12/3021. KFrazier"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2020-10-13","","","2020-11-25","11/25/2020 - Rcvd email confirmation that Nov monthly roster was processed and this provider was made effective with the requested eff date of 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2020-10-13","","","2020-12-14","12/14/2020 - Rcvd email confirmation from Galaxy Health that the November Delegation Roster was completed. DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-20","14485629","","2024-11-20","11/20/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2020-10-13","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2021-12-01","3873524","","2022-03-23","3/23/2022 Per follow-up note - 03.10.2022.S/W Lania of Boon Chapman @ 800-950-7040. Provider NPI# is on file  and is participating effective 12/1/2021 under the group and TIN #. Provider ID#3873524.  Physical location is on file.Call ref# 7943427.- DCannon"]
["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"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete",44117,"","","2021-08-06","8/6/2021 Rcvd confirmation from Caprock that provider is par and linked to TIN/locations effective 10/13/2020.  DCannon"]
["Ana M Rodriguez, APRN-FNP-BC",1437790284,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete",44117,"3546328","","2022-08-10","8/10/2022 Per First Health web portal provider is PAR and linked to group TIN/location effective 10/13/2020.  PID # 3546238.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2019-11-01","885680","519061","2020-03-10","03/10/2020 - Confirmed this proivder is linked to the group through PECOS group login - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Medicare","Participating","Enrollment Complete","2019-11-01","885680","519061","2020-03-10","03/10/2020 - Confirmed this proivder is linked to the group through PECOS group login - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["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","","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","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2013-11-01","9477656","","2021-11-15","11/15/2021 Per f/u note S/W Steven of Cigna @ 800-882-4462. NPI# for the provider is on file  shows LINKED and  Par under the group and TIN#,  effective 11/1/2019 , the physical location is on file and the Provider ID is 9477656.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Cigna","Participating","Enrollment Complete","2013-11-01","9477656","","2021-11-15","11/15/2021 Per f/u note S/W Steven of Cigna @ 800-882-4462. NPI# for the provider is on file  shows LINKED and  Par under the group and TIN#,  effective 11/1/2019 , the physical location is on file and the Provider ID is 9477656.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2020-03-31","1366762874","","2020-04-30","04/30/2020 - Signed into MMH group enrollment and found this provider is linked to the group at this serivce location EFF 3-31-2020. - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","TriCare Standard","Participating","Enrollment Complete","2020-03-31","1366762874","","2020-04-30","04/30/2020 - Signed into MMH group enrollment and found this provider is linked to the group at this serivce location EFF 3-31-2020. - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2020-02-13","1366762874","","2020-03-17","03/17/2020 - Rec'd email confirmation from the payer via a spreadsheet stating this provider is EFF at this service location - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Amerigroup","Participating","Enrollment Complete","2020-02-13","1366762874","","2020-03-17","03/17/2020 - Rec'd email confirmation from the payer via a spreadsheet stating this provider is EFF at this service location - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","","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","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak+"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","HealthSmart PPO","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak+"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","CAQH","Participating","CAQH Reattested","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2020-01-10","","","2021-01-14","1/14/2021 - Rcvd email from payer that provider is participating and loaded under tax ID effective 1/10/2020.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2020-01-10","","","2021-01-14","1/14/2021 - Rcvd email from payer that provider is participating and loaded under tax ID effective 1/10/2020.  DCannon"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete","2020-02-10","1366762874","West Texas Physicians Alliance","2020-07-08","07/08/2020 - Rec'd email from the payer stating this provider is EFF: \"Thank you for contacting our Customer Service Department at Multiplan/PHCS. At this time we show that Olufemi Aduroja is currently participating with the Multiplan, PHCS, and BeechStreet networks. The participation is through West Texas Physicians Alliance.\n\nEffective Dates:\nMultiplan-01/08/2020\nPHCS- 02/10/2020\nBeechStreet-02/10/2020\" - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Multiplan","Participating","Enrollment Complete","2020-02-10","1366762874","West Texas Physicians Alliance","2020-07-08","07/08/2020 - Rec'd email from the payer stating this provider is EFF: \"Thank you for contacting our Customer Service Department at Multiplan/PHCS. At this time we show that Olufemi Aduroja is currently participating with the Multiplan, PHCS, and BeechStreet networks. The participation is through West Texas Physicians Alliance.\n\nEffective Dates:\nMultiplan-01/08/2020\nPHCS- 02/10/2020\nBeechStreet-02/10/2020\" - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1366762874","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","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","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-02-01","1366762874","","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-02-01","1366762874","","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2020-05-01","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","","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","Rail Road Medicare","Participating","Enrollment Complete",43770,"P02428265","DW7662","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through payer portal - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Rail Road Medicare","Participating","Enrollment Complete",43770,"P02428265","DW7662","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through payer portal - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Enrollment Complete",44044,"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","","Aetna","Participating","Enrollment Complete",44044,"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","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","IMS","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2020-02-10","1366762874","","2020-10-05","Enrolled thru PHCS"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Boon Chapman","Participating","Enrollment Complete","2020-02-10","1366762874","","2020-10-05","Enrolled thru PHCS"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Superior","Participating","Enrollment Complete","2020-03-01","1366762874","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Superior","Participating","Enrollment Complete","2020-03-01","1366762874","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-25",""]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Omni PPO","Participating","Enrollment Complete","2020-01-31","1366762874","","2020-06-25",""]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2025-03-16","386007403","364596201","2020-08-13","8/13/2020 - signed onto TMHP and confirmed this provider is EFF and affilaited with the group - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Medicaid","Participating","Enrollment Complete","2025-03-16","386007403","364596201","2020-08-13","8/13/2020 - signed onto TMHP and confirmed this provider is EFF and affilaited with the group - Stacey Hudak"]
["Olufemi Aduroja, MD",1366762874,"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"]
["Olufemi Aduroja, MD",1366762874,"47-5554737","TX","","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2020-05-08","","","2024-01-29","1/29/2024 Rcvd confirmation from S&W that provider is PAR and linked to group TIN/location effective 5/8/2020.  DCannon"]
["James D Richardson, MD",1306827266,"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"]
["James D Richardson, MD",1306827266,"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"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-20","","","2024-11-20","11/20/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2021-01-26","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 1/26/2021. PA."]
["James D Richardson, MD",1306827266,"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"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-11-06","6886462","","2023-12-19","S/W JasonG of Cigna @ 1-800-882-4462. Per rep, Provider is in network with Cigna for the state of TX and linked to the group and TIN# effective 11/06/2023. Next recredentialing date is on 11/01/2026. PIN: 6886462. Servicing location is on file. Payer# 62308. Call ref# JasonG12192023. - Willie Ravas"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-28","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 01/28/2020. PA"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2020-01-24","937962","","2023-12-12","After receiving surrogacy, the provider already linked under this TIN effective 1/24/2020. MS"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-01-02","","","2024-01-09","Received confirmation via self service portal. MS"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2023-11-06","5693040","","2024-01-03",""]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-11-06","001320566","","2024-01-11","1/11/2024 Per UHC web portal provider is PAR and linked to group TIN/location effective 11/1/2023.  MPIN# 001320566003.  DCannon"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Enrollment Complete","","","","2024-05-22","Confirmed the provider is active and location linked. MS"]
["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"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2023-11-06","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 11/06/2023. PA."]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2023-11-06","","","2024-01-11","1/11/2024 Per UHC web portal provider is PAR and linked to group TIN/location effective 11/1/2023.    DCannon"]
["James D Richardson, MD",1306827266,"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"]
["James D Richardson, MD",1306827266,"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. 11/6/2023. and linked to location  400 Rosalind Redfern Grover PKWY, suite 230. PA."]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2024-01-01","","","2024-01-12","1/12/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["James D Richardson, MD",1306827266,"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"]
["James D Richardson, MD",1306827266,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","","","","2024-03-21","3/21/2024 Provider effective as of 5/4/2020 via Wellpoint roster. FC"]
["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.","First Health Coventry","Participating","Enrollment Complete","2022-12-19","3641811","","2023-07-24","Confirmed enrollment via online directory. MS"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2022-12-19","","","2023-02-16","2.16.2023 Per follow-up note - S/W Qjuana of Amerigroup @ 800-454-3730. Provider is on file and participating. Link under the group and TIN effective 12/19/2022. Location is on file. Provider ID is 15465202.   DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-11-21",""]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2022-12-19","","","2023-03-24","3/24/2023 In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Tricare Prime","Panel Closed","Panel Closed","","","","2022-11-28","11/28/2022 Tricare Prime panel is closed and currently not accepting requests to join the network.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Ambetter","Participating","Enrollment Complete","2023-02-01","","","2023-03-23","3/23/2023 Rcvd email Superior w/ confirmation from that provider is PAR and linked to group effective 2/1/2023.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete","2022-12-19","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","TriCare Standard","Participating","Enrollment Complete","2022-11-28","","","2022-12-28","12/28/2022  Per Humana Military/Tricare portal, provider is provider is PAR and linked to group effective 11/28/2022. DCannon"]
["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.","Cigna","Participating","Enrollment Complete","2023-01-01","0970113","","2023-12-19","Received confirmation effective 1/1/2023. MS"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2022-12-19","","","2023-02-08","2/8/2023 Rcvd email from UHC that January delegated roster provider load has been completed and provider is PAR and linked to group TIN effective 12/19/2022.  MPIN# 007288273.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Scott&White (First Care)","Participating","Enrollment Complete","2023-02-14","","","2023-08-24","8/24/2023 Per email rcvd from Scott & White provider is PAR and linked to group TIN/location effective 2/14/2023.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Aetna","Participating","Enrollment Complete","2023-01-09","6492054","","2023-04-03","04.03.2023 S/W Julie of Aetna @ 800-353-1232. Per rep, provider is showing participating with an Effective date 01/09/2023 and link under Group and TIN. Provider ID 6492054, Payer ID 60054 and Recredentialing date 12/16/2025. Service location is on file. Call ref#:6140925184. -Danico Gabriel Melendres"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2019-12-01","Q00373156","DS1746","2022-11-28","11/28/2022 Rcvd RR Medicare approval letter.  PTAN # Q00373156 - effective 12/1/2019.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellmed","Participating","Enrollment Complete","2022-12-19","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Wellcare","Participating","Enrollment Complete","2023-02-01","","","2023-03-23","3/23/2023 Rcvd email Superior w/ confirmation from that provider is PAR and linked to group effective 2/1/2023.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Humana","Participating","Enrollment Complete","2022-12-19","","","2023-08-31","8/31/2023 Per email from Marcus Wester at Humana January delegated roster has been completed and provider is PAR effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2023-02-01","","","2023-02-09","2/9/2023 Rcvd confirmation email from Superior that January delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 2/1/2023.  DCannon"]
["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"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Multiplan","Participating","Enrollment Complete","2022-12-19","","","2023-06-21","Rcvd effective date of 12/19/2022 from jessica.bess@MultiPlan.com.\nJen Videan"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Enrollment Complete",44914,"","","2023-02-28","2/28/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 12/19/2022.  DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Omni PPO","Participating","Enrollment Complete",44914,"","","2023-01-31","1/31/2023 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for December has been completed.  Provider is PAR and linked to group TIN effective 11/28/2022.   DCannon"]
["Stephanie D Crawford, FNP",1265081616,"27-4061759","TX","PE - Permian Cardiology Inc.","Galaxy Health","Participating","Enrollment Complete","2022-12-19","","","2023-03-09","3/9/2023 Per email rcvd from Karen Avalos at Galaxy, January monthly roster has been completed.  Provider is PAR and linked to group effective 12/19/2022.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","","","","2024-06-25","Medicaid revalidation approval rcvd. Jen Videan"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","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","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-07-23","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1447882915","","2024-06-28","Approval ltr rcvd. Provider eff 06/19/2024. Jen Videan"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Coventry Workers Comp","In Process","Add Info Submitted","","","","2024-08-19","8/19/2024 Submitted via roster to Coventry. FC"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2020-10-01","3372421","","2021-01-27","1/27/2021 - Per follow-up notes provider is on file and participating in network at location and under TIN effective 10/1/2020.  DCannon"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Superior","Participating","Enrollment Complete","2020-08-01","1447882915","","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"]
["Rachelle M Campos, APRN-FNP-BC",1447882915,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","","","","2024-09-10","Please see status updates under Alliance WC payor line. Jen Videan"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","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","Humana","Participating","Enrollment Complete","2020-01-01","1922008234","","2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Cindy Marriner, FNP",1922008234,"75-2656723","TX","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.\""]
["Cindy Marriner, FNP",1922008234,"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"]
["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","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Panel Closed","Panel Closed","","","","2021-08-05","8/5/2021 Payor is no longer accepting new providers into network unless provide significant amount of patients to be seen; therefore, per direction of MQA staff, they will no longer pursue enrollment.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1750796009","","2020-09-02","09/02/2020 - Rec'd email from the payer confirming this location add has been made - 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","First Health Coventry","Participating","Enrollment Complete","2021-08-01","3169156","","2022-02-04","2/4/2022 Per roster received from First Health provider is PAR and linked to group TIN/location effective 8/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2018-04-21","","","2021-04-23","4/23/2021 Upon review of the self-service portal, provider is non-network under group Tax ID effective 4/21/2018. KFrazier"]
["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","Medicare","Participating","In House Enrollment","2017-08-21","595054YM2M","00304W","2020-02-07","02/07/2020 - note on Payer List provided by the doctor states \"We credential our own Medicare.\" - Stacey Hudak"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","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","Superior","Participating","Enrollment Complete","2021-08-01","","","2021-08-05","8/5/2021 Rcvd email from Superior that monthly delegation roster for May is complete and providers are loaded under TIN/locations effective 8/1/2021.  DCannon"]
["Swetha Reddy Jangangari, MD",1750796009,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2018-08-01","3169156","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2018 PID # 3169156-tisha rader"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2018-09-19","1447701602","","2020-09-09","09/09/2020 - moved to completed status after reviewing the last note - Stacey Hudak"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2017-02-10","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 2/10/2017.  DCannon"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","In House Enrollment","In House Enrollment","2020-06-11","13952422","","2020-06-11","06/11/2020 - Provider did not supply CAQH login. Provider will maintain this info in-house - Stacey Hudak"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2019-12-01","1447701602","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - stacey hudak"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2017-09-01","1447701602","","2020-10-05","Enrolled thru PHCS"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Enrollment Complete",44348,"","",44463,"9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 6/1/2021.  DCannon"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","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"]
["Trinidad R Marquez, APRN-NP",1447701602,"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"]
["Trinidad R Marquez, APRN-NP",1447701602,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Rail Road Medicare","In House Enrollment","Enrollment Complete","2015-05-05","P02500765","DC8592","2020-08-28","08/28/2020 - moved to completed status after finding EFF info through payer site - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2015-08-20","5618134","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete","2018-08-03","1154767234","","2020-03-19","03/19/2020 - Rec'd email from the payer (Multiplan/Texas True Choice) has sent confirmation that this provider is EFF with Amerigroup - Stacey Hudak"]
["Chabacana Maxwell, FNP",1154767234,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2018-11-06","1154767234","","2020-08-19","8/19/2020 - Rec'd email confirmation from the payer stating this provider IS LINKED TO THE PRIMED DELEGATED AGREEMENT under this TIN/Service Locaiton. Provider is networked with the following: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network - Stacey Hudak"]
["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",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."]
["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","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","Aetna","Participating","Enrollment Complete","2015-09-01","","","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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete","2019-02-20","1891931341","","2020-06-30","6/30/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Tonya Murphy, FNP",1891931341,"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"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2019-02-19","","","2020-09-14",""]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-09-01","1891931341","","2020-09-02","09/02/2020 - Rec'd spreadsheet from the payer stating this location update has been made EFF 9-1-2020 - Stacey Hudak"]
["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","Omni PPO","Participating","Enrollment Complete","2020-08-01","","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","9085264","","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 # 9085264  DCannon"]
["Tonya Murphy, FNP",1891931341,"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"]
["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","Cigna","Participating","Enrollment Complete","2021-06-01","5244447","","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 5244447. KFrazier"]
["Tonya Murphy, FNP",1891931341,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2020-09-01","1891931341","","2020-09-23","09/30/2020 - moved to completed status after reviewing follow up complete - Stacey Hudak"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","In House Enrollment","In House Enrollment","","","","2021-08-03","8/3/2021 Medicare enrollment is done in-house by MCHS.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2019-10-21","","","2021-01-27","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","Medicaid","In House Enrollment","In House Enrollment","","","","2021-08-03","8/3/2021 Medicaid enrollment is done in-house by MCHS.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-08-01","1205299922","","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"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","868716","00304W","2020-09-21","09/21/2020 - Rec'd email confirmation that this service location has been added to the group enrollment - Stacey Hudak"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-29","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete","2019-10-29","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Michael Okoye, DO",1205299922,"83-0358685","TX","PE - Midland Community Healthcare Services","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","Cigna","Participating","Enrollment Complete","2020-09-10","0522362","","2020-09-14","9/14/2020 - Rec'd email from the payer stating \"Your effective date is 09/10/2020. Your provider identification number is 0522362.\" - stacey Hudak"]
["Jose Saucedo, APRN-FNP-BC",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, APRN-FNP-BC",1184265050,"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"]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Jose Saucedo, APRN-FNP-BC",1184265050,"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"]
["Jose Saucedo, APRN-FNP-BC",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, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2020-08-01","1184265050","","2020-08-06","8/6/2020 - Rec'd an email from the payer stating this provider was added to their database EFF: 8-1-2020 after receiving/processing the July roster - Stacey Hudak"]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","DO NOT ENROLL","In House Enrollment","","","","2021-08-04","7/31/2021 This will be processed by group. KFrazier"]
["Jose Saucedo, APRN-FNP-BC",1184265050,"83-0358685","TX","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"]
["Jose Saucedo, APRN-FNP-BC",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, APRN-FNP-BC",1184265050,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","Broadspire Services Inc.","Participating","Enrollment Complete","2023-12-18","","","2024-07-08","Contract complete. Effective 12/18/2023. Provider was listed on par provider roster submitted with contract. Jen Videan"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Rail Road Medicare","Participating","Enrollment Complete","2021-04-01","Q00110014","EA8735","2021-08-03","8/3/2021 Rcvd RR Medicare PTAN instantly after applying via RR Medicare website.  PTAN # Q00110014 effective 4/1/2021.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","Humana","Participating","Enrollment Complete","2022-06-01","","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 6/1/2022.  DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","TX","PE - Midland Medicine PA","Aetna","Participating","Enrollment Complete","2022-06-01","","","2022-06-02","6/2/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 6/1/2022.   DCannon"]
["Justin D Shanks, APRN-FNP-BC",1205477874,"84-2617748","ME","PE - Midland Medicine PA","Multiplan","Participating","Enrollment Complete","2021-08-13","","","2021-09-15","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-11-22","14615027","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Hagos Z Aymut, MD",1922548890,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-28","","","2021-01-14","1/14/2021 - Rcvd email from payer that provider is participating and loaded under tax ID effective 9/28/2020.  DCannon"]
["Suresh K Ravuri, MD",1750539268,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2021-01-26","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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2023-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2023. PA."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-12-02","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2023. PA."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-01-29","Enrollment is through Coventry. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","","Omni PPO","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 9/1/2024\n616 N Main st eff. 10/4/2024. AS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","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","Alliance WC","Participating","Enrollment Complete",45345,"","",45352,"Rcvd Welcome letter. Provider effective 02/23/2024. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2023-05-01","","","2023-07-27","7/27/2023 Rcvd email confirmation from Cigna that this group and Tax ID 47-3465832 are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the providers do not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-02-23","","","2024-03-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","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"]
["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","IMS","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2023-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2023. PA."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2018-11-20","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 11/20/2018.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","","Aetna","Participating","Enrollment Complete",43739,"6875567","",45589,"Received confirmation from Brandy Smith via roster provider is effective as of10/1/2019. FC"]
["Haley D Brennan, PA-C",1528430865,"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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["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","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2020-04-10","006901358","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 04/10/2020. PA."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","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","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","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","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","Alliance WC","Participating","Enrollment Complete","2024-05-29","","","2024-07-05","Per michelle.killough@pswca.org, providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2018-10-01","715814","","2020-06-15","06/15/2020 - Provider is effective per spreadsheet rec'd from the clinic - Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2023-05-01","","","2023-07-20","7/20/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete",45047,"","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 5/1/2023.  DCannon"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-01-30","Per Dee Dee Johnson at Texas Mutual 6301 Andrews Hwy has been added to provider's profile. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","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","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","Texas Mutual","Participating","Enrollment Complete","2024-07-26","","","2024-10-14","Per Dee Dee Johnson at Texas Mutual site visit completed on 07/26/2024. Jen Videan"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","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"]
["Haley D Brennan, PA-C",1528430865,"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"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Facility Enrollment","Facility Enrollment","","","","2020-10-09","10/9/2020 - Rec'd email from the clinic contact, Regina Stieger, stating that this payer has a facility only contract  in place- Stacey Hudak"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",45453,"","","2024-07-01","Group record has been updated to show this location as active. No individual enrollment is required. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","2023-10-26","Eastridge location is completed effective 10/9/2023. MS"]
["Haley D Brennan, PA-C",1528430865,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-07-28","","","2023-08-23","Provider is linked to the Briarwood location effective 7/28. MS"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2019-09-01","1215575576","","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"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-09","Panel is closed to new providers and locations. MS"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Triwest VA","In House Enrollment","In House Enrollment","","","","2021-01-13","1/6/2021 MQA Team is working with Representatives at BCBS-TX to ensure all providers are enrolled and loaded to participate with the VACCN network in a timely manner. However, we are currently awaiting a full roster of providers currently participating and will update all records accordingly upon receipt. Kfrazier"]
["Jordan Elizabeth Friday, NP",1215575576,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-09-09","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Satish Nayak, MD",1518053149,"57-1157825","TX","PE - Satish Nayak","Scott&White (First Care)","Participating","Enrollment Complete","2021-07-06","","","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 7/6/2021.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Wellmed","Participating","Enrollment Complete","2023-07-15","","","2023-10-02","10/2/2023 Per email response from UHC June delegated roster is provider load is complete.  Provider is PAR and linked to group TIN/location effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Boon Chapman","Participating","Enrollment Complete",45122,"","","2023-07-25","7/25/2023 Rcvd email confirmation from Jessica Bess at Multiplan that June roster has been processed and provider is PAR w/ group effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","HealthSmart PPO","Participating","Enrollment Complete",45047,"","","2023-11-13","11/13/2023 Per phone conversation with Lee Kinard at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","United Health Care","Participating","Enrollment Complete",45122,"","","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 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","TX","PE - ADA Adult and Children Family Clinic LLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-07-15","","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from June has been completed and provider is PAR effective 7/15/2023.  DCannon"]
["Abiodun A Okin-Ayileka, MD",1922328079,"84-4724927","ME","PE - ADA Adult and Children Family Clinic LLC","Boon Chapman","Participating","Enrollment Complete","2021-05-28","","","2021-09-15","9/15/2021 Received roster from Multiplan listing provider as PAR under group TIN/location effective 5/28/2021.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"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"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete",44098,"414415601","331090601","2021-10-06","10/6/2021 Confirmed license update complete via TMHP Portal.  DCannon"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete","2020-10-24","","","2020-11-03","11/3/2020 Confirmed via self-service portal provider is participating under Group Tax ID and location effective 10/24/2020. Kimberly Frazier"]
["Jonathan C Burkes, MD",1538571609,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","In Process","Payor Follow Up","2020-08-05","","","2025-01-03","Sent email to Mary Hanna requesting status on enrollment. PA."]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2020-10-07","1225277833","","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 12:22:11 PM. Your request was assigned reference number PR-5533577 .\" - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2019-12-13"," 9959784","","2020-06-26","06/26/2020 - moved to completed status after reviewing Follow Up Complete note - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete",42812,"1225277833","","2020-09-23","09/23/2020 - Moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete",42671,"","","2021-03-08","3/8/2021 Rcvd confirmation from Cigna that provider is now participating under TIN and linked to location effective 10/28/2016.  CPID # 7966637.  DCannon"]
["Carlos Molina, DO",1225277833,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete",44105,"1225277833","","2020-10-01","10/01/2020 - Rec'd email from the payer stating this provider has been uploaded to the PriMed agreement  - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2017-03-22","1225277833","","2020-09-23","09/23/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Carlos Molina, DO",1225277833,"26-3789190","TX","PE - Permian Physician Services","Galaxy Health","Participating","Enrollment Complete","2020-01-01","1225277833","","2020-10-05","10/5/2020 - Rec'd email back from the payer stating this enrollment has been completed - Stacey"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-10-04","Per Melody Starcher, they would like to hold off on Broadspire WC enrollment at this time. If they start to see a large amount of patients coming in with it, then they will reassess. 10/04/2023 Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Alliance WC","Participating","Enrollment Complete","","","","2023-09-27","Rcvd Welcome Ltr from Barry Harris at pswca.org. Provider is effective 09/22/2023. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-11-21","Permian Physician Services would like to hold off contracting with Broadspire at this time. Jen Videan"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete","2020-07-14","04223194","","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"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete","2020-10-01","1972942209","","2020-10-01","10/01/2020 - Rec'd completed spreadsheet from the payer stating this provider is EFF - Stacey Hudak"]
["Alyssa Tochterman, MD",1972942209,"75-1997880","TX","PE - Andrews County Hospital District","Sedgwick","Participating","Enrollment Complete","2024-05-21","1972942209","","2024-05-22","Approval ltr rcvd. Effective date 05/21/2024. 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",44300,"","","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","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1083867147","","2020-08-21","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"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"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2017-06-08","1083867147","751997880","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Margaret Merriam, DO",1083867147,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete","2019-11-01","1083867147","","2020-10-02","10/02/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Margaret Merriam, DO",1083867147,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2017-06-05","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 6/5/2017.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","HealthSmart PPO","Participating","Enrollment Complete",43734,"1669617981","","2020-07-01","07/01/2020 - Rec'd email confirmation from the payer that this provider is EFF - Stacey Hudak"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","First Health Coventry","Participating","Enrollment Complete","2010-01-15","","","2023-05-02","5/2.2023 Per confirm par status -  Per rep, provider is showing participating with an effective date 1/15/2010 and link under the Group and TIN. Provider ID 2099013.  Service location is on file. Call ref#:610334. DCannon"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"26-3789190","TX","PE - Permian Physician Services","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-02-01","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"26-3789190","TX","PE - Permian Physician Services","Cigna","Participating","Enrollment Complete","2019-09-01","6837080","","2020-12-04","12/4/2020 Rcvd email from Cigna confirming provider is PAR at location.  PID: 6837080; TIN: 263789190\nEffective date: 09/01/2019.  DCannon"]
["Jennifer B Hada-Ondriezek, DPM",1669617981,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete",42034,"1669617981","","2020-08-04","8/4/2020 - Rec'd email confirmation from the payer that this provider is EFF with group AFM NPI - Stacey Hudak"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete",44622,"","","2022-04-18","4/18/2022 Per Tricare portal, provider is par as of 3.2.2022. Cbankston"]
["Shannan Clawson, NP",1972073906,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2021-03-01","Q00078955","CE1588","2021-06-01","6/1/2021 Immediately assigned RR PTAN Q00078955 which is effective 3/1/2021 under group RR PTAN CE1588. KFrazier"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Kristie M Chu, MD",1780078089,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44326,"","","2022-06-29","6/29/2022 Per email received from Priscilla Albertine at MQA from a follow-up email she received from USA PPO provider is PAR and in linked to group TIN effective 5/10/2021.  DCannon"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Barbara Norris, NP-C",1720353592,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete",41766,"1720353592","751997880","2020-08-19","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Enrollment Complete",44048,"","","2021-04-09","4/9/2020 Rcvd roster from Mary Rodriguez <mary.rodriguez@90degreebenefits.com> at Caprock listing provider as participating under TIN.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","Sedgwick","Participating","Enrollment Complete","2024-05-21","1184035313","","2024-05-22","Approval ltr rcvd. Effective 5/21/2024. Jen Videan"]
["Stephanie Jean Fitzgerald, MD",1184035313,"26-3789190","TX","PE - Permian Physician Services","First Health Coventry","Participating","Enrollment Complete","2023-05-28","3133441","","2023-07-25","7/25/2023  Per First Health online provider directory provider is PAR and linked to group/locations  effective 5/28/2023.  DCannon"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","CAQH","Participating","CAQH Reattested","2024-11-25","","","2024-11-25","11/25/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Stephanie Jean Fitzgerald, MD",1184035313,"75-1997880","TX","PE - Andrews County Hospital District","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"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Medicaid","Participating","In House Enrollment","2020-03-31","205592303","324676101","2020-10-15","10/15/2020 - this enrollment is maintained by the clinic. Rec'd a copy of the effective letter to update the database for use with other payers - Stacey Hudak"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete","2020-07-17","","","2022-07-23","7/23/2022 Per email from Marcie Eckhart-Haven at Multiplan provider is PAR and linked to group TIN effective  7/17/2020. DCannon"]
["Cynthia A Hill, CNS",1225271224,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2020-09-02","","","2021-01-29","1/29/2021 - Rcvd roster from Scott&White (First Care) confirming participation of provider with TIN and location effective dates.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete",42942,"1306928098","","2020-07-30","7-30-2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Aetna","Participating","Enrollment Complete","2016-04-01","1306928098","","2020-07-20","07/20/2020 - moved to completed status after reviewing Follow up Complete note. This provider has a DIRECT contract - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","HealthSmart PPO","Participating","Enrollment Complete","2011-11-01","","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 11/01/2011.  DCannon"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","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"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","Superior","Participating","Enrollment Complete","2017-01-01","1306928098","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","","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","","Scott&White (First Care)","Participating","Enrollment Complete","2016-03-30","1306928098","","2020-08-04","8/4/2020 - Rec'd email from the payer confirming this provider is enrolled/linked to this group NPI - Stacey Hudak\n\n8/20/2020 - Rec'd a spreadsheet from the payer stating this provider is affilaited with the PRIMED DELEGATED ROSTER under this TIN/Service Location. This provider is networked with\nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","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","","1306928098","1427297134","2021-10-14","10/14/2021 In-House Enrollment. KFrazier"]
["Rahul Dinesh Puri, MD",1306928098,"75-1997880","TX","PE - Andrews County Hospital District","Aetna","Participating","Enrollment Complete","2016-04-01","1306928098","","2020-07-20","07/20/2020 - moved to completed status after reviewing Follow Up Complete note. Provider has a DIRECT contract  - Stacey Hudak"]
["Rahul Dinesh Puri, MD",1306928098,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","Participating","Enrollment Complete","2021-11-18","","","2021-12-14","12/14/2021 Per tircare portal provider linked to location as of 11/18/2021. Cbankston"]
["Paul Slaughter, DO",1184626749,"75-1997880","TX","PE - Andrews County Hospital District","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"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","USA PPO","Participating","Enrollment Complete","2021-01-26","1312337","","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"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","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"]
["Maria Montero, MD",1508218843,"75-2656723","TX","PE - North Big Spring Family Care","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["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","Humana","Participating","Enrollment Complete","2018-07-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 7/1/2018.  DCannon"]
["Christopher Stansell, FNP",1285065946,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2013-11-01","","","2020-12-24","12/24/2020 Provider is certified as non-network provider under Group Tax ID and location. KFrazier"]
["Lindsay M Friesenhahn, PA",1558979013,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-11-06","Received confirmation via phone call from German Aviles. Provider participating as of 10/7/2024. FC"]
["Lindsay M Friesenhahn, PA",1558979013,"75-2656723","TX","PE - Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-11-07","Received email confirmation from Keandra Walker, provider is PAR and linked to TIN & location, eff. 10/07/2024. PA."]
["Lindsay M Friesenhahn, PA",1558979013,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2024-10-07","","","2024-12-05","Spoke with UHC rep Luis via online chat., ref# 04900276. Provider is par, eff. 10/07/2024. PA."]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2020-09-17","","","2021-01-27","1/27/2021 - Rcvd confirmation email that provider is participating and linked to location and TIN effective 9/17/2020.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete",44116,"","","2021-01-18","1/18/2021 - Rcvd confirmation email from Cigna that provider has loaded and is participating under TIN and location effective 10/12/2020 CPID # 4138818.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","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"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-12-14","","","2021-01-26","1/26/2021 - Per follow-up notes provider is par with TIN and location effective 12/14/2020.  DCannon"]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","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","Scott&White (First Care)","In Process","Application Submitted","","","","2024-11-15","Submitted location add via delegated roster submission. PA."]
["Leslie Michelle Rowland, FNP",1720111883,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",44222,"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","Amerigroup","Participating","Enrollment Complete","2020-10-13","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 10/13/2020.  DCannon"]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2020-12-01","","","2021-02-02","2/2/2021 - Rcvd confirmation from payer that provider is participating and linked to TIN effective 12/1/2020.  DCannon"]
["Ni Adams, APRN-NP",1194355339,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2022-03-02","","","2022-03-09","3/9/2022 Per Tricare portal provider is certified and in network with location as of 3/2/2022. Cbankston"]
["Rachel Ann Murphy, RD",1124637160,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete","2020-12-07","","","2021-01-06","1/6/2020 - Rcvd confirmation from payor that provider load is complete.  DCannon"]
["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","","Triwest VA","Enrollment on Hold","Enrollment on Hold","","","","","RHC."]
["Eliana Kelley, APRN-FNP-BC",1184278251,"75-1997880","TX","PE - Andrews County Hospital District","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"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","TriCare Standard","Participating","Enrollment Complete","2022-08-18","","","2022-09-15","9/15/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 8/18/2022.  DCannon"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete",44791,"","","2024-02-28","Re-Cred has been completed. eff 8/18/2022. MS"]
["Julie Parker, APRN-NP",1720538606,"75-1997880","TX","PE - Andrews County Hospital District","USA PPO","Participating","Enrollment Complete","2021-01-07","1310979","","2021-03-12","3/12/2021 Per verification on payor website USAMCO.com provider is loaded as participating.  Rcvd Roster LeNetrice Myart with provider numbers and effective dates for providers.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","Medicare","Participating","Enrollment Complete","2023-12-12","00320K","","2024-01-24","Novitas received the providers signatures after the rejection letter was sent out. The client decided to wait to see if Novitas would still go ahead and process the application. Approval letter received eff 12/12/2023. MS"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","Galaxy Health","Participating","Enrollment Complete","2023-07-17","","","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 7/17/2023.  DCannon"]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","Scott&White (First Care)","Participating","Enrollment Complete","2024-02-01","","","2024-09-04","Roster received from the payor. The provider is listed as PAR, effective 2/1/2024, and is linked to the TIN and location. PA."]
["Daniel J Dominguez, APRN-FNP-BC",1720610447,"74-2348334","TX","PE - Permian Gastroenterology PA","Rail Road Medicare","Participating","Enrollment Complete","2023-12-12","Q00658568","CI6074","2024-02-07","Received welcome letter. MS"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Paula Kaye Brookings, APRN-FNP-BC",1295136034,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Amerigroup","Participating","Enrollment Complete",44203,"","","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"]
["Meagan Leighann Cunningham, APRN-FNP-BC",1891302931,"75-1997880","TX","PE - Andrews County Hospital District","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-11-04","397001403","364596201","2021-03-01","3/1/2021 Upon review of the TMHP portal, provider has been approved and assigned TPI 397001403 under Group and effective date is that of Medicare approval, which is 11/14/2020. KFrazier"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2021-02-08","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 2/8/2021.  DCannon"]
["Bola O Jaiyeola, NP",1235605064,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2021-02-08","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 2/8/2021.  DCannon"]
["Rebecca McClay, DNP",1629613070,"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"]
["Rebecca McClay, DNP",1629613070,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing","2021-03-15","6557282","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2024-12-23","Per updates@primehealthservices.com, provider has been added effective 05/23/2023. Jen Videan"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","",45660,"application is still pending signature, client notified. MS"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2025-01-03","application is still pending signature, client notified. MS"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-12-20","Pending Medicare approval. MS"]
["Ernest J Buck, MD",1861504987,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","",45649,"TSCA and required documents submitted to wwtxcontracts@texasmutual.com. Jen Videan"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-20","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-20","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Ernest J Buck, MD",1861504987,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-12-20","Application submitted for all 5 locations. MS"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Pending Info/Document","","","","2024-12-23","Missing signed Sedgwick forms. Emailed Priscilla. Jen Videan"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-12-20","Panel is closed to new enrollments. mS"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","",45649,"Please see status updates under Alliance WC payor line. Jen Videan"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-12-23","Please see status updates under Alliance WC payor line. Jen Videan"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-12-23","Emailed roster to brandhi_wilson-woods@corvel.com. Jen Videan"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-12-23","Emailed roster to brandhi_wilson-woods@corvel.com. Jen Videan"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2024-12-23","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application. Jen Videan"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Application Submitted","","","","2024-12-23","Submitted application via portal, case# 12233292. PA."]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2024-12-20","No enrollment is needed. Provider is loaded and billing out under the group TIN. MS"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45642,"","","2024-12-16","12/16/2024 CAQH Sweep completed pklika"]
["Ernest J Buck, MD",1861504987,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-12-16","","","2024-12-16","12/16/2024 CAQH Sweep completed pklika"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2023-01-01","","",44950,"1/24/2023 Rcvd email from Priscilla Albertine at MQA of confirmation that provider is PAR in Superior Health plan under the group TIN effective 1/1/2023.   DCannon"]
["Amanda Compton, MD",1679953517,"75-1997880","TX","","Tricare Prime","Participating","Enrollment Complete","2021-07-08","","","2022-02-17","2/17/2022 Per Tricare portal, provider is linked to location eff 7/8/2021. Cbankston"]
["Amanda Compton, MD",1679953517,"26-3789190","TX","PE - Permian Physician Services","Caprock (CapStar)","Participating","Re-Credentialing","2022-12-01","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD",1679953517,"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,"26-3789190","TX","PE - Permian Physician Services","IMS","Participating","Re-Credentialing","2022-12-01","","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Amanda Compton, MD",1679953517,"75-1997880","TX","PE - Andrews County Hospital District","Superior","Participating","Enrollment Complete",44317,"","","2021-05-04","5/4/2021 Rcvd email from Superior confirming that the providers are PAR and loaded under TIN/locations effective 5/1/2021.  DCannon"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-10-25","","","2024-11-12","Welcome ltr rcvd. Effective 10/25/2024. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-11","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-11","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-07-01","","","2024-10-25","Received confirmation from Brandy Smith via delegated roster provider participating as of 7/1/2024. FC"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete",45487,"","","2024-07-29","Received email provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45574,"","","2024-10-10","Approval ltr rcvd. Effective 10/09/2024. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45574,"","","2024-10-10","Approval ltr rcvd. Effective 10/09/2024. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-20","","","2024-06-18","Received email confirmation provider is now par with BCBSTX, eff. 6/20/2024, participating in the following networks:\n\nBAV - Blue Advantage HMO\t\nBCA - BlueChoice PPO\t\nHME - Health Select\t\nHMO - Blue Essentials\t\nPMC - Medicare Advantage PPO"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-20","","","2024-06-18","Received email confirmation provider is now par with BCBSTX, eff. 6/20/2024, participating in the following networks:\n\nBAV - Blue Advantage HMO\t\nBCA - BlueChoice PPO\t\nHME - Health Select\t\nHMO - Blue Essentials\t\nPMC - Medicare Advantage PPO"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","In Process","Payor Follow Up","","","","2024-12-31"," Sent email to payor requesting status. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-07-18","Submitted via delegated roster on 7/15/2024. FC"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["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","Humana","Participating","Enrollment Complete","2024-07-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/01/2024.  PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",45474,"","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/01/2024.  PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2024-06-11","","","2024-06-25","Per Broadspire, Moving forward please send all update requests to Updates@primehealthservices.com only. Please note, that our team will no longer be providing direct responses to update requests. We understand the importance of updated provider information and rest assured, your request is in our system, and our dedicated team will handle it promptly.  Our team will reach out should any additional information be needed. But, no further updates will be given on requests and no confirmation of completion will be given. Effective date is date of contract 05/23/2023. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2024-10-08","Approval ltr rcvd. Effective 09/18/2024. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2024-10-08","Approval ltr rcvd. Effective 09/18/2024. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 7/1/2024. AS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-06-11","","","2024-08-30","Approval Ltr rcvd. Effective 09/01/2024. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-11-26","App submitted via Tricare portal. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-10-02","Per the Tricare portal, she is linked to this location. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-07-24","","","2024-10-02","Per the Tricare portal, she is linked to this location. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2024-12-31","Per UHC rep Yashary via online chat ref# 04937533, provider is showing OON. Will resubmit application via roster submission, PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45474,"","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. \nLocation is linked to provider per payor website. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",45548,"","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. \nLocation is linked to provider per payor website. PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-05-10","Q00774406","DX4335","2024-07-01","received confirmation. MS"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","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","Participating","Enrollment Complete",45590,"","","2024-11-12","Please see status updates under Alliance WC payor line. Jen Videan"]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","In Process","Payor Follow Up","","","","2024-12-31","Per UHC rep Yashary via online chat ref# 04937533, provider is showing OON. Will resubmit application via roster submission, PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","In Process","Payor Follow Up","","","","2024-12-31","Per UHC rep Yashary via online chat ref# 04937533, provider is showing OON. Will resubmit application via roster submission, PA."]
["Lisa A. Hernandez, APRN-FNP-BC",1942766092,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","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"]
["Karthik Chakrala, DO",1043633233,"47-5554737","TX","PE - Midland Inpatient Medical Association","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","","CAQH","Participating","CAQH Reattested",45617,"","","2024-11-21","11/21/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","Ambetter","Participating","Enrollment Complete",44652,"","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","","United Health Care","Participating","Enrollment Complete","2021-05-10","","","2022-06-11","6/11/2022 Per email from Janice Edwards @ UHC delegated roster provider load has been completed and providers PAR and linked to group TIN effective 5/10/2021.  DCannon"]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Orlando Enrique Garner Cruz, MD",1417309105,"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.\""]
["Orlando Enrique Garner Cruz, MD",1417309105,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2021-07-01","1R4716","0008AH","2021-07-13","7/13/2021 Rcvd email from Medicare stating that providers Medicare application has been approved.  PTAN # 1R4716 - effective 7/1/2021"]
["Kristin M Moose, APRN-FNP-BC",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","CAQH","Participating","Pending Info/Document","2024-03-29","","","","03/29/2024 Cannot reattest inactive DEA. Need active DEA to reattest. Updated COI wthompson"]
["Kristin M Moose, APRN-FNP-BC",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","BCBSTX","Participating","Confirm Par Status","2023-04-07","","","2024-06-18","Per BCBSTX rep Angelica Johnson, provider is PAR, linked to TIN/location, eff. 04/1/2023. PA"]
["Kristin M Moose, APRN-FNP-BC",1215213970,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Wellcare","Participating","Enrollment Complete","2024-01-01","","","2024-01-22","1/22/2024 Per email rcvd from Superior, December roster is complete provider is PAR and linked to group TIN/locations effective 1/1/2024.  DCannon"]
["Emily N Baker Butler, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","","","","2024-04-30","Received confirmation the provider's medicare record has been updated with the correct last name. MS"]
["Emily N Baker Butler, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2021-09-01","","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Emily N Baker Butler, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Emily N Baker Butler, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2021-08-01","1R7343","0008AH","2021-07-21","7/21/2021 Received Medicare PTAN approval letter.  PTAN # 1R7343 - effective 8/1/2021 DCannon"]
["Emily N Baker Butler, DO",1053817940,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2021-08-09","","","2024-04-19","4/19/2024- Submitted new last name via delegated roster on 4/15/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","","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"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-12-20",""]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2021-08-13","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Application Resubmitted","2021-09-01","6764944","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","6764944","","2023-09-05","9/5/2023 Per email from Priscilla Albertine at MQA she received a roster confirming that provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2021-09-01","6764944","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/1/2021. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2021-10-08","","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 10/08/2021.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Application Resubmitted","2024-02-01","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2021-09-15","","","2024-07-19","Received roster from HP Delegation; provider is PAR and linked to TIN and location, eff. 09/15/2021. PA."]
["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","Amerigroup","Participating","Application Submitted","2024-08-31","","","2024-09-30","As per Cassandra Dunagon submit application via delegated roster. Submitted delegated roster on 9/30/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 6/12/2023. AS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Application Submitted","2024-08-31","","","2024-09-30","As per Cassandra Dunagon submit application via delegated roster. Submitted delegated roster on 9/30/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-29","","","2024-07-05","Per michelle.killough@pswca.org, providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",44378,"","","2023-09-08","Provider is currently enrolled with all locations under WesTex. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-07-01","","","2024-06-28","Group enrollment has been approved and this location has been linked and is active effective 7/1/2024. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-11-26","App submitted via Tricare 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","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status",44513,"00007017728","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 11/13/2021. PA."]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","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","Caprock (CapStar)","Participating","Enrollment Complete","2020-04-15","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024 location has been added, eff. 04/15/2020 . PA"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","","IMS","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-09-01","9/1/2023 Per email received from Caprock provider has been added to new location 4705 Briarwood Ave. and  6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Application Resubmitted","2021-08-13","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["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","In Process","Payor Follow Up","","","","2024-12-31"," Sent email to payor requesting status. PA."]
["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","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"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","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","Humana","Participating","Enrollment Complete","2021-09-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 9/1/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","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"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","3578768","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","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","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","Sedgwick","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2021-09-01","","","2023-02-28","2/28/2023 Per First Health web portal provider is PAR and linked to group TIN/location effective 9/1/2021.  DCannon"]
["Jeffery Dickson, NP",1851865067,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45400,"","","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","Humana","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","","Aetna","Participating","Enrollment Complete","2021-09-01","6764944","","2024-05-20","5/202/24 Spoke to Alex call ref#6192816326 616 N Main St  location participating as of 02/1/2024. FC"]
["Jeffery Dickson, NP",1851865067,"47-3465832","TX","","Caprock (CapStar)","In Process","Add Info Submitted","","","","2024-06-17","Submitted Yukon address via delegated roster on 6/14/2024. FC"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Ambetter","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,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-01-03","","","2023-03-20","3/20/2023 Rcvd email from Caprock that March delegation roster load has been completed.  Provider is PAR and linked to group TIN/location effective 1/3/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","","Multiplan","Participating","Application Resubmitted","2021-08-13","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","","First Health Coventry","Participating","Enrollment Complete","2023-11-01","","","2023-10-31","10/31/2023 Rcvd copy of signed and executed contract from First Health.  Provider and group are PAR effective 11/1/2023.  DCannon"]
["Sandra Maerzacker, MD",1396190823,"92-1786827","TX","Sandra Maerzacker, MD, PLLC","Medicaid","Participating","Enrollment Complete","2024-05-01","1396190823","","2024-06-14","Approval ltr rcvd. Effective 05/01/2024. Jen Videan"]
["Neil P Doctor, MD",1619322492,"92-0763047","TX","PE - VYVO Therapeutics","Humana","In Process","Payor Follow Up","","","","2024-12-26","Enrollment pending, ref# CO-18532123. PA."]
["Neil P Doctor, MD",1619322492,"92-0763047","TX","PE - VYVO Therapeutics","IMS","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Neil P Doctor, MD",1619322492,"92-0763047","TX","PE - VYVO Therapeutics","Aetna","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-22","","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-06-01","","","2023-07-19","7/19/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2022-08-01","007514238","","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 8/1/2022.  MPIN # 007514238 DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2022-08-01","","","2023-07-17","7/17/2023 Rcvd email from Superior that provider is PAR and linked to new location via group delegated roster effective 6/1/2023.  DCannon"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2023-06-06","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Brenda Campos-Ilesanmi, APRN-NP",1740807304,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-06-06","","","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 6/6/2023.  DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Enrollment Complete","2021-11-01","","","2021-12-31","12/31/2021 Rcvd email from German Aviles <german.aciles@imsm.net> at IMS/OMNI stating that the monthly delegated roster provider loads for October and November have been completed.  Provider is PAR and linked to location/TIN effective 11/1/2021. DCannon"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","","Aetna","Participating","Add Info Submitted","2021-11-01","6261482","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Add Info Submitted","2021-11-01","12182506","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","","Multiplan","Participating","Add Info Submitted","2022-04-05","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Addis Getahun, MD",1548765183,"47-5554737","TX","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","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"]
["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","IMS","Participating","Add Info Submitted","2021-10-29","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-11-22","","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Add Info Submitted","2021-12-22","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Martha Denise Mourning, NP",1922552959,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Enrollment Complete","2021-10-29","","","2022-04-05","4/5/2022 Rcvd email from Joe Rodriguez at Amerigroup confirming provider is PAR and linked to group TIN/location effective 10/29/2021.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","","IMS","Participating","Add Info Submitted","2021-11-18","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-12-30","","","2024-12-30","12/30/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","","Multiplan","Participating","Enrollment Complete","2021-11-18","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 11/18/2021.  DCannon"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Add Info Submitted","2021-11-18","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Daniel Gellan, MD",1811315880,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2021-11-18","","","2022-02-04","2/4/2022 Rcvd email from G. Aviles @ IMS/Omni that provider is PAR and linked to group TIN/location effective 11/18/2021.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2022-12-20","","","2023-10-30","Was finally given access to the group TIN. This provider was already enrolled with the group. MS"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Amerigroup","Participating","Enrollment Complete","2023-05-01","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Sedgwick","Participating","Enrollment Complete","2024-02-21","","","2024-02-21","Rcvd approval ltr. Provider is effective 02/21/2024. Jen Videan"]
["Brandon H Rayne, PA",1912482209,"46-0950925","TX","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","Gallagher","Delegated - Third Party","Thru Other Payor","","","","2024-02-01","Check Coventry portal for enrollment status. Provider currently not showing as active.  Jen Videan"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Permian Physician Services","CAQH","Participating","CAQH Reattested","2024-11-19","","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","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","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 - Andrews County Hospital District","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-10-04","Per Melody Starcher, they would like to hold off on Broadspire WC enrollment at this time. If they start to see a large amount of patients coming in with it, then they will reassess. 10/04/2023 Jen Videan"]
["Ragini Sastry, DO",1942568431,"75-1997880","TX","PE - Andrews County Hospital District","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"]
["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","","Humana","Participating","Enrollment Complete",44662,"","","2022-07-14","7/14/2022 Per email received from Humana provider is PAR and linked to group TIN/location effective 4/11/2022.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","","Superior","Participating","Enrollment Complete",44682,"","","2022-05-03","5/3/2022 Rcvd email from Superior that April delegation roster has been completed and provider is PAR and linked to group TIN/location effective 5/1/2022.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2022-04-08","","","2022-09-16","9/16/2022 Received approval letter from Scott & White.  Provider is PAR and linked to group TIN/location effective 4/8/2022.  DCannon"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Judy J Jia, MD",1588983134,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-02-21","4120898","","2022-06-21","6/21/2022 - Per follow-up note - NPI# for the provider is on file, shows par under the group and TIN#, effective 2/21/2022, the physical location is on file and the Provider ID is 4120898.  Call ref # Camaria6142022. - DCannon"]
["Claude B Nguyen, MD",1619130929,"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"]
["Claude B Nguyen, MD",1619130929,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Enrollment Complete",44622,"","","2022-05-26","5/26/2022 Rcvd email from G. Aviles at IMS/OMNI stating that the monthly delegated roster provider loads for April has been completed.  Provider is PAR and linked to location/TIN effective 3/2/2022. DCannon"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",44687,"","","2024-01-03","Provider is now linked to the correct address effective 12/14/2023. MS"]
["John H Ownby, MD",1558343988,"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"]
["John H Ownby, MD",1558343988,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",44682,"","","2022-07-01","7/1/2022 Received May Monthly Validation roster from Superior and provider is PAR and linked effective 5/1/2022.  DCannon"]
["Elena Krendelshchikova, APRN-NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","United Health Care","Participating","Enrollment Complete","2022-05-13","6105828","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 05/13/2022.  PA"]
["Elena Krendelshchikova, APRN-NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Elena Krendelshchikova, APRN-NP",1356714406,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Enrollment Complete","2024-08-05","","","2024-10-01","Received confirmation via email, provider participating as of 8/5/2024. FC"]
["Megan E Rosa, PA",1720698640,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","In Process","Payor Follow Up","","","","2024-11-27","Application is processing. MS"]
["Megan E Rosa, PA",1720698640,"75-2656723","TX","PE - Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-11-07","Received email confirmation from Keandra Walker, provider is PAR and linked to TIN & location, eff. 10/07/2024. PA."]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Wellmed","Participating","Enrollment Complete","2022-08-27","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 8/27/2022.  DCannon"]
["Amanda J Wilson, FNP-BC",1609484419,"84-2617748","TX","PE - Midland Medicine PA","Aetna","Participating","Enrollment Complete","2022-05-09","6390660","","2022-06-08","6/2/2022 Per Aetna provider directory provider is PAR and linked to group TIN/location effective 5/9/2022.   DCannon"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44743,"","","2023-08-21","Rcvd TMHP welcome letter, provider effective 07/01/2022. Jen Videan"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",44743,"","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 07/01/2022. PA."]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2023-08-24","","","2024-02-13","Re-Credentialing has been completed. MS"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete",45162,"","","2024-02-07","ReCred has been completed. MS"]
["Kendra Cooper, APRN-FNP-BC",1780334193,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-07-01","","","2023-07-11","Received confirmation from Client. MS"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete",44690,"","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/09/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Tricare Prime","Participating","Enrollment Complete",44680,"","","2022-06-02","6/1/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 4/29/2022.  DCannon"]
["Valarie Ramirez Alcala, PA",1790251031,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Wellmed","Participating","Enrollment Complete","2022-05-11","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 5/11/2022.  DCannon"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Gallagher","Participating","Enrollment Complete","","","","2024-01-26","Confirmed via Coventry Portal. MS"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Corvel Healthcare Corp.","Participating","Enrollment Complete",44782,"","","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","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"]
["Caroline D Hammond, PA",1720698574,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Aetna","In Process","Payor Follow Up","2022-05-09","6227554","","2025-01-03","Sent email to Mary Hanna requesting status on enrollment. PA."]
["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","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","2022-05-09","","","2022-08-11","8/11/2022 Rcvd email from Scott & White that monthly delegated roster for June has been completed and providers are loaded to group delegation roster effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete","2022-05-09","","","2022-07-24","7/24/2022 Per email from Marcie Eckhart-Havens Multiplan July delegated roster has been completed  and provider is PAR and linked to group TIN effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","Participating","Enrollment Complete","2022-07-24","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 7/24/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","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","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","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","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","IMS","Participating","Enrollment Complete","2022-05-09","","","2022-07-05","7/5/2022 Rcvd email from G.Aviles at IMS/OMNI that delegation roster provider load for June has been completed.  Provider is PAR and linked to group effective 5/9/2022.  DCannon"]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","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","Ambetter","Participating","Enrollment Complete","2022-06-01","","","2022-06-20","6/20/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Innocentia Ifunanya Onyemetu, NP",1790457075,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","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","2022-05-09","6689991","","2022-06-21","6/21/2022 Per follow-up note - S/w Joan of Aetna @ 800-353-1232. Provider NPI# is on file for the provider and is participating effective 05/09/2022  under the group and TIN#. PIN: 6689991. Physical location is on file. Call ref# 6094998732. - DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Superior","Participating","Enrollment Complete",44774,"","","2022-08-10","8/10/2022 Per roster received from Superior July monthly delegated submission is complete and provider is PAR and linked to group TIN/locations effective  8/1/2022.  DCannon"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","USA PPO","Participating","Enrollment Complete","2022-06-20","","","2023-10-23","10/23/2023 Per roster received from USA PPO 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","HealthSmart PPO","Participating","Enrollment Complete","2022-06-20","","","2023-07-11","Received confirmation from Client. MS"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","PE - Premier Texas Kidney Care, PLLC","Cigna","Participating","Enrollment Complete","2022-05-01","0461877","","2022-07-15","7/15/2022 Per confirm par status note on 6/3/2022 - S/W Frank at Cigna, who confirmed provider is credentialed in TX through a delegation and is linked to tax ID as of 5/1/2022. Provider ID is 0461877. Ref # is frank 6/3/2022. HSmith"]
["Sridhar R Allam, MD",1700061819,"88-1668292","TX","","Cigna Healthspring","Panel Closed","Panel Closed","","","","2024-04-09","Received panel closed letter. MS"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2022-09-12","","","2022-10-17","10/17/2022 Per email received from German Aviles at IMS/OMNI monthly delegation roster provider load for September has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.   DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2022-09-12","","","2022-11-01","11/1/2022 Per Healthsmart website provider is PAR and loaded under TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",44788,"2H6458","0008AH","2022-08-25","8/25/2022 Per PECOS provider is PAR and linked to group/location effective 8/15/2022.  PTAN # 2H6458.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete",44816,"003315195","",44866,"11/1/2022 Rcvd email from UCH that provider load has been completed and provider is PAR and linked to group TIN/location effective 9/12/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","","Galaxy Health","Participating","Enrollment Complete",44816,"","","2022-09-27","9/27/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for September has been completed.  Provider is PAR and linked to group TIN effective 8/29/2022.  DCannon"]
["Vishnu S Brahmandam, MD",1548447899,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2022-09-12","","","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","","CAQH","Participating","Pending Info/Document","2024-06-04","","","2024-08-13","incorrect username and password"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete",44760,"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","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-06-20","","","2022-08-17","8/17/2022 Per email from Karen Avalos at Galaxy delegated roster for July is complete and provider is loaded effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete",44732,"","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Christopher A Stack, MD",1568704971,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2022-06-20","","","2022-10-11","10/11/2022 Per email from Priscilla Albertine at MQA she received an update from Joe Rodriguez at Amerigroup.  Provider is PAR and linked to group TIN/location effective 6/20/2022.  DCannon"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete",44830,"","","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","CAQH","Participating","CAQH Reattested","2024-11-20","","","2024-11-20","11/20/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Annabelle Rivera, APRN-NP",1871250191,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-09-26","","","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 9/26/2022.  DCannon"]
["Joyce O. Alase, MD",1295168318,"88-2797281","TX","PE - Healing Hands Medical Clinic","Wellmed","Participating","Enrollment Complete","2022-10-04","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 10/04/2022.  DCannon"]
["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","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"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2023-02-09","3357467","","2023-02-16","02.16.2023  Per follow-up note - S/W Stephanie of Cigna @ 1-800-882-4462. Per rep, provider is showing participating with an Effective date 02/09/2023 and link under the Group and TIN. Provider ID 3357467, No Payer ID and Recredentialing date 02/09/2026. Service location is on file.  DCannon"]
["Hannah Heflin, RD",1366172579,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Travelers WC","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Corvel Healthcare Corp.","Participating","Enrollment Complete","2022-09-26","","","2023-05-02","05.02.2023  Per follow-up note - S/W Marina of Corvel Healthcare Corp @ 800-872-0820. Per rep, provider is showing PAR and link under the Group and Tax ID with an Effective date 09/26/2022. Provider ID 1341506, Recredentialing date is 09/26/2025. Service location is on file. Call ref#:Marina05022023.-Danico Gabriel Melendres"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Ambetter","Participating","Enrollment Complete",44866,"","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that October delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 11/1/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","Scott&White (First Care)","Participating","Enrollment Complete",44879,"","","2023-02-09","2/9/2023 Rcvd email from Priscilla Albertine at MQA that provider is PAR and linked to group TIN effective 11/14/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"75-1997880","TX","PE - Andrews County Hospital District","Travelers WC","Participating","Enrollment Complete","","","","2024-01-31","Per Coventry portal provider is enrolled. Jen Videan"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","USA PPO","Participating","Enrollment Complete","2022-09-26","","","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 9/26/2022.  DCannon"]
["Richard Glenn Eby, MD",1598260325,"26-3789190","TX","PE - Permian Physician Services","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,"75-1997880","TX","PE - Andrews County Hospital District","Texas Mutual","Participating","Enrollment Complete","2023-08-01","","","2023-08-08","Rcvd approval letter. Effective 08/01/2023. Jen Videan"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2022-11-28","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-21","","","2024-11-21","11/21/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2022-11-28","","","2024-12-03","Received confirmation via delegated roster from Emily Starr 11/22/2024. Provider participating 11/4/2024. AS"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Add Info Submitted","2022-11-28","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Kathryn A. Lagus, APRN-FNP-BC",1285983155,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",44958,"","","2023-02-09","2/9/2023 Rcvd confirmation email from Superior that January delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 2/1/2023.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete",44896,"","","2022-12-29","12/29/2022 Rcvd confirmation email from Superior that November delegation roster has been processed and provider has been loaded to delegation roster and PAR w/ group effective 12/1/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Enrollment Complete",44865,"","","2023-02-01","2/1/2023 Per email response from Amerigroup Provider Relations-Texas provider is PAR and linked to group effective 10/31/2022.  PID# 14835000.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete",45205,"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","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","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","Boon Chapman","Participating","Enrollment Complete","2022-10-31","","","2023-07-26","7/26/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group and location effective 10/31/2022.  DCannon"]
["Marisela Sample, LPC",1396470357,"83-0358685","TX","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",""]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Medicaid","Participating","Enrollment Complete",45397,"1619603255","","2024-06-13","Approval ltr rcvd. Effective 04/15/2024. Jen Videan"]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","USA PPO","Participating","Enrollment Complete",44963,"","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 02/06/2023. PA."]
["Taylor Allison Arrington, APRN-FNP-BC",1619603255,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-22","1/22/2024 Pending Multiplan enrollment.  DCannon"]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-02-01","","","2024-04-16","Received email from Karen Avalos confirming roster completed; provider is PAR under TIN: 75-2656723, eff. 02/01/2024. Location 1805 S County Road linked. PA."]
["Sacha A Stanley, APRN-FNP-BC",1780399857,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-02-01","4920546","","2024-03-19","Received email confirming enrollment. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2023-08-25","8/25/2023 Per email received from Caprock provider has been added to new locations  4705 Briarwood Ave and 6950 Eastridge Rd. effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-01","","","2024-07-04","7/4/2024 provider participating as of 2/1/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","","Omni PPO","Participating","Enrollment Complete","2024-02-01","","","2024-01-26","1/26/2024 Per email received from German Aviles at IMS/OMNI, January delegated roster has been completed.  Provider is PAR and linked to group TIN/location effective 2/1/2024.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",45047,"","","2023-08-25","8/25/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete",45086,"","","2023-11-13","Per Michelle Killough @ Alliance WC provider is effective 06/09/2023.  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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",45201,"","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-06-26","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 06/26/2023. PA."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["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","","",45407,"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","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n6301 Andrews Hwy 5/6/2024\n616 N Main St & 4705 Briarwood Ave eff. 6/12/2023. AS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-12-19","Group has Ancillary contract where all midlevel services are billed under the group contract rather than Ind. claims. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-06-26","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 06/26/2023. PA."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-08-15",""]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-03-31","3671302","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-01","","","2023-09-26","Confirmed provider is loaded at the Briarwood location effective 9/1/23. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",45016,"","","2023-09-07","9/7/2023 Per email received from Jessica Bess at Multiplan provider is PAR and linked to group TIN/location effective 3/31/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",45323,"","","2024-05-20","5/20/2024- Spoke to DJ A. call ref# 6192837355, 616 N Main st location participating as of 2/1/2024. FC"]
["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","","","","2023-10-23","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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","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"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-19","Per Galaxy rep Karen A., location add request in process. PA."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-03-17","Q00521373","","2023-07-27","7/27/2023 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group effective 3/17/2023. PID # Q00521373.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","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","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-04","8/4/2023 Per Humana Military web portal Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","","IMS","Participating","Enrollment Complete","2023-10-02","","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-05-15",""]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-07-28","","","2023-07-31","07/31/2023 - Received email from BCBSTX confirming provider is participating with Blue Essentials, Blue Advantage HMO, Blue Choice PPO, Medicare Advantage PPO and Health Select, effective 07/28/2023. PA."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Participating","Enrollment Complete","","","","2024-01-31","Confirmed via Coventry portal the provider is enrolled. MS"]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["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","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","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stephanie R Powell, PA-C",1538714076,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","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","Wellmed","Participating","Enrollment Complete",45047,"","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff. 5/01/2023. PA"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",44988,"Q00521328","DX4335","2023-07-27","7/27/2023 Rcvd RR Medicare approval letter.  Provider is PAR and linked to group effective 3/3/2023. PID # Q00521328.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2023-05-01","","","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","Wellmed","Participating","Enrollment Complete","2023-05-01","","","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","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","Travelers WC","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","First Health Coventry","Participating","Enrollment Complete",45047,"","","2023-08-23","08.23.2023 S/W Bridgette of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 05/01/2023. Provider ID 3674804. Physical location is on file. Call ref#:734006. - Danico Gabriel Melendres"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45301,"","","2024-01-18","Received confirmation of enrollment .MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2023-05-01","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","Caprock (CapStar)","Participating","Enrollment Complete","2023-05-01","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024 location has been added, eff 05/01/2023. PA"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-04-19",""]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",45413,"","","2024-05-09","Received email from Marina Martinez of USA MCO, provider is PAR and 616 Main St location linked, eff. 05/01/2024."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","Participating","Enrollment Complete","2023-10-02","","","2023-09-12","9/12/2023 Per email received from Caprock provider has been added to new location 6301 Andrews Hwy effective 10/2/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-12-02","Roster emailed to Brandhi_Wilson-Woods@Corvel.com. Jen Videan"]
["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","Sedgwick","Participating","Enrollment Complete","2023-10-18","","","2024-03-05","Per spneast@sedgwickcms.com address has been added to provider's profile effective 10/18/2023. Jen Videan"]
["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","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-10-02","","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 10/2/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","","","","2023-05-18","Cigna does not require individual enrollment for facility based contracts. Provider will be billing claims under the facility, not individually. MS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","2023-05-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff. 5/01/2023. PA"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-05-06","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 9/4/2024\n6950 Eastridge Rd, 4705 Briarwood Ave, 616 N Main St. eff. 6/12/2023\n6301 Andrews Hwy 5/6/2024.\nAS"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-05-01","007509811","","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","","Omni PPO","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacey Jo Guse, NP",1184108664,"47-3465832","tx","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"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Application Resubmitted","2023-05-01","","","2024-09-27"," Unable to get confirmation from Brandy or Hannah if the requested termination would be stopped. I submitted application via delegated roster on 9/27/2024 except Longview and Greenbriar. FC"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45047,"","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Stacey Jo Guse, NP",1184108664,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete",45047,"","","2023-07-20","7/20/2023 Per email received from Galaxy May delegated roster has been processed and provider is PAR and linked to group effective 5/1/2023.  DCannon"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-12-11","Permian Physician Services would like to hold off contracting with Broadspire at this time. Jen Videan"]
["Suhail Sami Daye, MD",1639251481,"26-3789190","TX","PE - Permian Physician Services","Wellcare","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"]
["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","Amerigroup","Participating","Enrollment Complete","2019-08-30","","","2023-08-17","8/17/2023 Per email from Priscilla Albertine at MQA she received a roster from Amerigroup confirming that provider is PAR and linked to group TIN/location effective 8/30/2019.  DCannon"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","","","","2024-12-11","Enrollment  complete for 4214 Andrews Hwy\nSuite 102 Midland, TX effective 05/11/2023."]
["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","HealthSmart PPO","Participating","Enrollment Complete",45078,"","","2024-12-03","Received confirmation via delegated roster from Emily Starr 11/22/2024. Provider participating 11/4/2024. AS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2023-06-01","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","In House Enrollment","Add Info Submitted","","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2023-05-01","2W8694","","2023-08-01","Received enrollment completed email effective 5/1/2023. \nApplication Tracking ID: T071820230002417\n NPI ID: 1083672778\n Medicare ID: 2W8694\n Name: DAVID HAYNIE\n State: TX\n Form Type: 855I\n Date: 08/01/2023\n Status: APPROVED"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","PE - Premier Family Care, Inc","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","","Medicaid","Participating","Enrollment Complete","2023-10-02","","","2024-12-08","Provider is active with this location effective 10/02/2023. Jen Videan"]
["David Powell Haynie, MD",1083672778,"75-2656723","TX","","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"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-06-12","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["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","HealthSmart PPO","Participating","Enrollment Complete","2024-02-01","","","2024-07-04","7/4/2024 provider participating as of 2/1/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-01-24","Re-Cred application approved. 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","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","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-19","Per Galaxy rep Karen A., location add request in process. PA."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-06-01","9695700","","2023-10-24","10.24.2023 S/W PhilC of Aetna @ 1-800-353-1232. Per rep, Provider is in network with Aetna and linked to the group and TIN# effective 06/12/2023. Next recredentialing date is 06/12/2026. PIN: 9695700. Servicing location is on file. Payer# 60054. Call ref# 6167813673. - Willie Ravas"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2023-06-12","","","2023-10-12","10/12/2023 Per email received from Jessica Bess at  Multiplan provider is PAR and linked to group TIN/locations effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2023-06-10","Q00596481","DX4335","2023-11-08","Received enrollment confirmation. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45200,"","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 10/2/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","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","First Health Coventry","Participating","Enrollment Complete","2023-06-01","2243378","","2023-10-26","10/26/2023 S/W Bridgette of First Health @ 800-226-5116, per rep provider is showing participating and link under the Group and TIN with an Effective date 06/01/2023. Provider ID 2243378. Physical location is on file. Call ref#:754015. - DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-06-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["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","Texas Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document",45441,"","","2024-08-01","missing current CAQH username and password"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-05-29","","","2024-08-01","missing current CAQH username and password"]
["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","Corvel Healthcare Corp.","Participating","Enrollment Complete","2023-12-29","","","2024-01-04","Rcvd welcome letter. Provider is effective 12/29/2023. Jen Videan"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","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","Medicare","Participating","Enrollment Complete","2023-06-10","","","2023-09-21",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45209,"","","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","USA PPO","Participating","Action Needed","2024-09-13","","","2024-12-17","Roster dated 12/11/2024 has provider listed under \"Wegner.\" Need to resubmit name update to payor. PA."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-18","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["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","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","Humana","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2023-06-12","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 6/12/2023.  DCannon"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45536,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd 5/21/2024\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 9/1/2024\n616 N Main st eff. 6/12/2023. AS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",45453,"","","2024-07-01","Location has been linked to the group record which rolls to the individual providers record as well. There is no further enrollment needed. MS"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete",45089,"","","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","Boon Chapman","Participating","Enrollment Complete",45089,"","","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","Application Resubmitted","2023-06-01","2243378","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-06-12","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 wxcept Longview location. FC"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","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. Jen Videan"]
["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","Aetna","Participating","Enrollment Complete","2023-06-01","9695700","","2024-05-20","5/20/2024 Spoke to irish B call ref# 6192826533 616 N Main St location eff as of 2/1/2024. FC"]
["Kelly Burrows, FNP",1518292077,"47-3465832","tx","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"]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-08-04",""]
["Kelly Burrows, FNP",1518292077,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility Enrollment","In House Enrollment","","","","2023-08-04",""]
["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",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"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Participating","Enrollment Complete","2023-05-29","1073983193","","2023-08-21","Dana Bell par effective 05/29/2023 at 5000 Briarwood Ave Midland, TX 79707. Jen Videan"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Participating","Enrollment Complete",45075,"1073983193","","2023-08-21","Dana Bell par effective 05/29/2023 at 5000 Briarwood Ave Midland, TX 79707. Jen Videan"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","TriCare Standard","Participating","Enrollment Complete","2023-06-22","1073983193","","2024-08-23","Briarwood Location: Provider is active and linked to this location eff 7/9/2024. MS"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Boon Chapman","Participating","Enrollment Complete",45139,"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","HealthSmart PPO","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Galaxy Health","Participating","Enrollment Complete",45139,"1073983193","","2023-09-19","9/19/2023 Per email received from Galaxy August delegated roster has been processed and provider is PAR and linked to group/location effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","667985783","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Participating","Enrollment Complete","2023-08-12","006397593","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and locations effective 8/12/2023.  MPIN # 006397593.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete",45170,"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","Omni PPO","Participating","Enrollment Complete","2023-08-01","1073983193","","2023-09-05","9/5/2023 Per email received from IMS/OMNI May delegated roster has been processed and provider is PAR and linked to group effective 8/1/2023.  DCannon"]
["Dana L Bell, APRN-FNP-BC",1073983193,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete",45352,"3480191","","2024-04-08","Per First Health rep Giovann, 1-800-226-5116, ref# 1001519, provider is PAR and linked to both locations (5000 Briarwood and 5424 19th Str), eff. 3/1/2024. PA."]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Gallagher","Participating","Enrollment Complete",45088,"","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","IMS","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","","Liberty Mutual","Participating","Enrollment Complete",45088,"","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","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","Alliance WC","Enrollment Stopped","Enrollment Stopped","","","","2023-12-19","Per MQA, I received verbal confirmation from the practice, they are currently not desiring enrollment with WC payors. Please discontinue pursuit until further notice. Jen Videan"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Coventry Workers Comp","Participating","Enrollment Complete",45088,"","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","","Cigna","Participating","Enrollment Complete","2023-10-11","","","2023-10-12","Received enrollment confirmation email. MS"]
["Laura Sonnenburg, PA",1003214511,"84-2617748","TX","PE - Midland Medicine PA","Medicaid","Participating","Enrollment Complete","2023-06-01","","","2024-01-05","Welcome letter rcvd. Provider effective 06/01/2023. Jen Videan"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete",45177,"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","Superior","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"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Suresh K Kota, MD",1609921782,"47-5554737","TX","","HealthSmart PPO","Participating","Add Info Submitted","2023-09-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Tokkie Orogbemi, CPNP",1790435014,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Tricare Prime","Participating","Enrollment Complete","2019-11-27","","","2024-01-26","Confirmed provider is credentialed and in network with Tricare. MS"]
["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","PE - Premier Family Care, Inc","IMS","Participating","Add Info Submitted","2023-09-19","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2023-09-19","","","2023-11-07","11/7/2023 Per email received from Galaxy October delegated roster has been processed and provider is PAR and linked to group/location effective 9/19/2023.  DCannon"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2023-09-19","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","","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","Add Info Submitted","","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Rahul P Sinha, MD",1598182412,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Participating","CAQH Reattested","2024-11-19","","","2024-11-19",""]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","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"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","HealthSmart PPO","Participating","Add Info Submitted","2023-09-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","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"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","","Multiplan","Participating","Add Info Submitted","2023-09-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Whitney E Wyers, APRN-FNP-BC",1972003119,"27-4061759","TX","PE - Permian Cardiology Inc.","Rail Road Medicare","Participating","Enrollment Complete","2023-11-13","Q00602404","","2023-11-16","Received confirmation. MS"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Tricare Prime","Panel Closed","Panel Closed","","","","2023-08-17","Unfortunately, at this time the network is closed. Humana Military thanks you for your interest in joining the TRICARE East Region network to provide care for our beneficiaries. At this time, we are not currently expanding our network based on your specialty and location within the East Region. Please understand that every market is different based on the beneficiary population and the types of services needed in a particular location. Thank you again for your inquiry.   You can monitor the link below for network opening status.    Join the TRICARE East network (humanamilitary.com)   Humana Military is currently not accepting requests to join the medical surgical network. We apologize for the inconvenience, but we hope you check back soon to see if we are accepting network providers."]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-08-22","008866025","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 8/22/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellcare","Participating","Enrollment Complete","2023-10-01","","","2023-10-16","10/16/2023 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 10/1/2023.  DCannon"]
["Esther Ebele Ihediwa, APRN-FNP-BC",1215633011,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete",45160,"","","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","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","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",45160," 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"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Add Info Submitted","2023-09-08","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","First Health Coventry","Participating","Add Info Submitted",45177,"3746322","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2023-09-08","008870712","","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"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted","2023-09-08","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Madhusmita Panda, MD",1134756364,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2023-09-24","6C1375","","2023-10-27","Received welcome letter eff 9/24/23. MS"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Zurich","In Process","Confirm Par Status","2024-03-01","","","2024-09-11","Emailed Kathryn.schiewe@zurichna.com for par status. Jen Videan"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","","Omni PPO","Participating","Add Info Submitted",45177,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-11-09","","","2023-12-07","Provider is linked to this location eff 11/9/23. MS"]
["Abbie Estes, PA",1952088411,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Boon Chapman","Enrollment Stopped","Enrollment Stopped","","","","2023-10-20","10/20/2023 Must be enrolled in Multiplan in order to be enrolled in Boon Chapman.  Multiplan was not chosen as a payor to enroll with on the payor list submitted.  DCannon"]
["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","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","","","2023-11-05","Provider linked to Andrews Hwy location eff 10/26/23. 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",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",45139,"2Y3057","","2023-08-29","Received completed enrollment. MS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-08","008870743","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2023-09-08","008870743","","2023-09-28","9/28/2023 Rcvd email confirmation from UHC that September delegated roster has been completed.  Provider is PAR and linked to group/location effective 9/8/2023.  DCannon"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2023-09-08","6474406","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/8/2023. FC"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-17","Received email confirmation from PPHP, provider is linked to the location/TIN, eff. 7/11/2024. PA."]
["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","Wellmed","Participating","Enrollment Complete","2023-09-08","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 9/08/2023..  PA"]
["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","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"]
["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","Amerigroup","Participating","Enrollment Complete",45569,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd eff. 5/21/2024\n616 N Main St. & 4705 Briarwood Ave  eff. 9/8/2023. AS"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete",45177,"","","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","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","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-09-08","3746844","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["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","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete",45069,"","","2023-08-29","Per Benjamin Richbourg at Corvel provider has been loaded into their system.  Per Benjamin they do not have effective dates for individual providers. Only effective date is the one on the contract which is 05/23/2023. Jen Videan"]
["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","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","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Liberty Mutual","Panel Closed","Panel Closed","","","","2023-12-21","12/21/2023 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"]
["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","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","Humana","Participating","Enrollment Complete","2023-09-08","","","2024-06-21","Received email confirmation from Marcus Wester, provider is par and linked to TIN/location, eff. 09/08/2023. PA"]
["Tiffany Nicol Bynum, APRN-FNP-BC",1376006403,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Triwest VA","Facility 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","2023-09-22","","","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","Alliance WC","Participating","Enrollment Complete","2023-09-22","","","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","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","","HealthSmart PPO","Participating","Enrollment Complete","2023-10-09","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 10/9/2023.  DCannon"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2023-10-03","","","2023-10-09","10/9/2023 Per email received from Scott & White provider is PAR and linked to group effective 10/3/2023.  DCannon"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Add Info Submitted","2023-10-09","","","2024-10-15","Submitted recredentialing application via delegated roster. FC"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete",45173,"","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Rony Ninan, MD",1750526182,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2023-10-09","","","2024-01-29","1/29/2024 Per Humana provider portal provider is PAR and linked to group TIN/location effective 10/9/2023.  DCannon"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","Participating","Add Info Submitted","2023-11-06","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2023-12-01","","","2024-06-25","As per Teresita (call ref# 1105034) provider participating as of 12/1/2023, listed as Internal  Medicine. FC"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2023-11-06","","","2023-12-20","12/20/2023 Per email from Jessica Bess at Multiplan November delegated roster provider load is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Add Info Submitted","2023-11-06","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Rajnarsing R Chennamaneni, MD",1164689634,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2023-09-08","1083394977","","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"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-02-01","953232543","","2024-01-24","1/24/2024- received email confirmation from Scarlett A. (Scarlett_Abigail@bcbstx.com), provider is par, eff. 02/01/24."]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","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","Humana","Participating","Enrollment Complete","2023-09-08","1083394977","","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"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Participating","CAQH Reattested","2024-11-04","16016463","","2024-11-04","11/04/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Amanda Dee Flores, APRN-FNP-BC",1083394977,"75-2781652","TX","PE - West Texas Allergy, PA","Humana","Participating","Enrollment Complete","2023-09-08","1083394977","","2024-01-24","1/24/2024 Rcvd email from Priscilla Albertine at MQA with an updated from Humana.  Provider is PAR and linked to group TIN and both locations effective 9/8/2023.  DCannon"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","","","","2024-12-03","Received confirmation via delegated roster from Emily Starr 11/22/2024. Provider participating 11/4/2024. AS"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","","Amerigroup","Participating","Enrollment Complete","2023-11-08","","","2023-12-27","12/27/2023 Per Amerigroup web portal provider is PAR and linked to group TIN/location effective 11/8/2023.  DCannon"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Add Info Submitted",45238,"","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Ankit Ashwin Patel, MD",1083979322,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2024-01-01","","","2024-01-17","1/17/2024 Per follow-up email from Scott and White provider is PAR effective 1/1/2024.  DCannon"]
["Billy S Gao, MD",1699092304,"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.  11/06/2023 and linked to TIN. PA"]
["Billy S Gao, MD",1699092304,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Billy S Gao, MD",1699092304,"75-2656723","TX","PE - Premier Family Care, Inc","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"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","","Aetna","Participating","Enrollment Complete","2023-12-04","","","2024-01-22","1/22/2024 Per Aetna online portal provider is PAR and linked to group TIN/locations effective 12/4/2023.  DCannon"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","First Health Coventry","Participating","Enrollment Complete","2024-01-01","","","2024-06-25","As per Teresita (call ref# 1105034) provider participating as of 1/1/2024, listed as Family Practice. FC"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","","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"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","","HealthSmart PPO","Participating","Add Info Submitted","2023-12-04","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Sudhir K Chiluka, MD",1912452053,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete",45264,"00010938653","","2024-01-22","1/22/2024 Per UHC portal provider is PAR and linked to group TIN/location effective 12/4/2023. MPIN# 00010938653.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"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 locations effective 11/06/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"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 locations effective 11/06/2023.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"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"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2023-11-06","006258398","","2023-12-28","12/28/2023 Per email from UHC provider is PAR and linked to group TIN/location effective 11/6/2023. \nMPIN # 006258398.  DCannon"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","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"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","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"]
["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","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","Caprock (CapStar)","Participating","Enrollment Complete",45236,"","","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"]
["Briana Janene Smith, APRN-FNP-BC",1215488754,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","Participating","Enrollment Complete",45236,"","","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"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-02-05","","","2024-03-20","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","TriCare Standard","Participating","Enrollment Complete","2023-12-13","","","2024-01-02","Provider is linked to this location effective 12/13/23. MS"]
["Neel N Shah, MD",1861752529,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-05-03","8633787","","2024-05-06","Received enrollment confirmation. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"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"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete",45200,"Q00615975","","2023-12-07","Received approval letter. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2023-11-06","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that November delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","","","","2024-11-12","11/12/2024 location added, see other CAQH tab for exp dates pklika"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","2023-10-01","2231549","","2024-01-30","Confirmed enrollment via Coventry portal. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2023-12-15","","","2024-02-16","Please see status updates under Alliance WC payor line. Jen Videan"]
["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","Scott&White (First Care)","Participating","Enrollment Complete","2023-12-15","","","2024-07-19","Received roster from HP Delegation; provider is PAR and linked to TIN/location, eff. 12/15/2023. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","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","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","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","","","2023-10-26","Briarwood location is confirmed eff 10/16/23. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45225,"","","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,"","","2023-10-26","Briarwood location is confirmed 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","","","2023-10-26","Longview location is confirmed eff 10/16/23. 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","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","","First Health Coventry","Participating","Application Resubmitted","2023-12-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2024-01-23","00390310977","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/23/2024. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2023-11-06","","","2023-12-18","12/18/2023 Per email from Karen Avalos at Galaxy November delegated roster is complete.  Provider is PAR and linked to group TIN/locations effective 11/6/2023.  DCannon"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",45236,"003261515","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 11/06/2023. PA."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","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","Application Resubmitted","2023-12-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2023-12-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45535,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 11/6/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 11/6/2023. AS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 11/6/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 11/6/2023. AS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-11-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-11-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Jeremy Davis Dominguez, PA",1841508462,"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"]
["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","","","","2023-12-04","Enrollment complete for 4705 Briarwood, 6950 Eastridge and 210 W Longview. Effective 12/01/2023. Jen Videan"]
["Jeremy Davis Dominguez, PA",1841508462,"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"]
["Jeremy Davis Dominguez, PA",1841508462,"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"]
["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",45224,"","","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","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","","Aetna","Participating","Enrollment Complete",45323,"","","2024-05-20","5/20/2024- Spoke to Audrey call ref #6192822735 616 N Main participating as of 2/1/2024. FC"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete",45628,"5995568","","2024-12-20","Received confirmation email. MS"]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",45413,"","","2024-05-09","Received email from Marina Martinez of USA MCO, provider is PAR and 616 Main St location linked, eff. 05/01/2024."]
["Jeremy Davis Dominguez, PA",1841508462,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2023-10-01","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"]
["Bailey Bergman, PA",1447851639,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete",45349,"","","2024-03-05","Provider has been linked to this location eff 2/27/24. MS"]
["Bailey Bergman, PA",1447851639,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2024-06-04","","","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","HealthSmart PPO","Participating","Enrollment Complete","2024-03-11","","","2024-07-04","7/4/2024 provider participating as of 3/11/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Payor Follow Up",45323,"","","2024-12-19","Received December Validation report from SHP.  Provider is listed PAR with both the Star plans and the MMP. However, the effective date listed on the report is 12/1/2024. A request has been submitted to SHP via email to backdate the effective date to 2/1/2024. PA."]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Provider Type Not Enrolled","Enrollment Stopped","","","","2024-01-31","1/31/2024 Per LaNetrice Myart @ USA PPO, registered dieticians are not credentialed/enrolled through USA PPO.  There fore enrollment will be stopped for this provider.  DCannon"]
["Brittany P Price, RD",1922875160,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2024-07-02","","","2024-09-19","Approval ltr rcvd. Jen Videan"]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2024-02-05","","","2024-05-24","Received email confirmation from Multiplan rep Jessica Bess (jessica.bess@multiplan.com), provider is PAR, eff. 02/05/2024. PA."]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2024-02-05","","","2024-05-20","5/20/2024 Provider participating as of 2/5/2024 via April roster. FC"]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","In House Enrollment","In House Enrollment","","","","2024-01-09",""]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete",45323,"6H2375","","2024-02-02","Approval showing in Medicare approved enrollment record. MS"]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2024-02-05","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff. 02/05/2024.  PA."]
["Carrie M Watson, APRN-NP",1700513504,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2024-03-01","","","2024-06-04","Received email confirmation from shpdelegation@superiorhealthplan.com provider is PAR, linked to TIN and locations, eff. 03/01/2024. PA"]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","2024-02-20","2/20/2024- Pending Multiplan enrollment.  FC."]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Scott&White (First Care)","Participating","Enrollment Complete","2024-03-15","","","2024-09-04","Roster received from the payor. The provider is listed as PAR, effective 03/15/2024, and is linked to the TIN and location. PA."]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Enrollment Complete","2024-02-05","","","2024-05-29","As per Kodi from IMS, provider participating as of 2/5/2024 received via email. FC"]
["Alberto Fernandez, PA",1912697970,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Travelers WC","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","PE - Premier Family Care, Inc","Boon Chapman","Pending Other Enrollment","Pending Other Enrollment","","","","",""]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","","Wellcare","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2024-08-05","","","2024-10-07","Received confirmation via email, provider participating as of 8/5/2024. FC"]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","","USA PPO","Participating","Enrollment Complete","2024-08-15","","","2024-10-16","Received email confirmation from LaNetrice Myart provider is par, linked to TIN/location, eff. 8/15/2024. PA."]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Enrollment Complete","2024-08-05","","","2024-10-01","Received confirmation via email, provider participating as of 8/5/2024. FC"]
["Nikolas V St Cyr, MD",1538659487,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2024-08-05","","","2024-10-04","Received confirmation via email from Geman Aviles, provider participating as of 8/5/2024. FC"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","","Medicare","Participating","Enrollment Complete",45474,"6Q7671","","2024-05-20","Received enrollment confirmation. MS"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","","Medicaid","In Process","Payor Follow Up","","","","2024-11-13","Application in PE Review status. Jen Videan"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-07-01","","","2024-10-31","Approval ltr rcvd. Provider effective 07/01/2024. Jen Videan"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, effective 10/1/2024, linked to TIN & location, effective 10/1/2024."]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","In Process","Application Submitted","","","","2024-09-13","Submitted application via delegated roster. FC"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, effective 10/1/2024, linked to TIN & locations, effective 10/1/2024."]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2024-09-09","","","2024-11-08","Received confirmation via email from Jessica Bess, provider participating as of 9/9/2024. FC"]
["Rathnavali Katragadda, MD",1750885075,"75-2656723","TX","","First Health Coventry","In Process","Payor Follow Up","","","","2024-07-23","Provider not yet loaded into system. Still processing. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45358,"","","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",45358,"","","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","Texas Mutual","Participating","Enrollment Complete",45413,"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","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","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Action Needed",45548,"","","2024-12-17","Resubmit locations- 616 N Main St, 6301 Andrews, 6950 Eastridge, and 5514 Big Spring-  to payor. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, the provider is listed par, eff. 9/13/2024. \nPer payor website, payor is linked to 3490 Yukon, 4705 Briarwood,  and 210 Longview.  PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2024-11-27","Roster emailed to updates@primehealthservices.com. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-28","","","2024-07-05","Per michelle.killough@pswca.org, providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website. Jen Videan"]
["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","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","Participating","Enrollment Complete",45387,"","","2024-07-31","Received email confirmation provider is par and linked to TIN/location, eff. 04/05/2024. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","Broadspire Services Inc.","Participating","Enrollment Complete",45358,"","","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","Pending Contracting","","","","2024-05-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd., 616 N Main st, 4705 Briarwood Ave eff. 10/4/2024\n3490 E Yukon Rd eff. 8/31/2024. AS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","Tx","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)","Participating","Enrollment Complete","2024-03-11","","","2024-07-23","As per Kim Patterson from Caprock, provider participating as of 3/11/2024 via email. FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-04-05","8474477","","2024-05-20","5/20/2024- Spoke to Max C call ref# 6192813282 provider participating with all 5 locations effective as of 4/5/2024, provider listed as a SPEC. FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete",45387,"8474477","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 4/5/2024. FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","","","2024-04-24","Approval ltr rcvd. Effective 07/22/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-19","Per Galaxy rep Karen A., location add request in process. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted",45387,"","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",45387,"","","2024-06-26","Spoke to Rick P call ref# 1106851 he indicated provider is participating as of 4/5/2024 with all 5 locations. FC"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete",45597,"","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",45387,"","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 04/05/2024. PA"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",45387,"","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 04/05/2024. PA"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",45471,"","","2024-07-31","Received email confirmation location has been added, eff. 06/28/2024. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","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","HealthSmart PPO","Participating","Enrollment Complete",45387,"","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 4/5/2024. AS"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-03-01","","","2024-07-31","Received email confirmation provider is par and linked to location, eff. 3/01/2024. PA."]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45457,"1184490161","","2024-06-14","Approval ltr rcvd. Effective 06/14/2024. Jen Videan"]
["Caroline G Clements, APRN-FNP-BC",1184490161,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45457,"1184490161","","2024-06-14","Approval ltr rcvd. Effective 06/14/2024. 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","Multiplan","Opt Out","Application Submitted",45358,"","","2024-04-15","4/15/2024 Delegated roster submitted.  FC"]
["Robert John Cornell, MD",1457331803,"75-1997880","TX","PE - Andrews County Hospital District","Multiplan","Participating","Enrollment Complete",45383,"","","2024-08-16","Received confirmation from Jessica Bess via email provider participating as of 4/1/2024. FC"]
["Robert John Cornell, MD",1457331803,"75-1997880","TX","PE - Andrews County Hospital District","Scott&White (First Care)","Participating","Enrollment Complete","2024-07-01","","","2024-09-04","Roster received from the payor. The provider is listed as PAR, effective 7/1/2024, and is linked to the TIN and location. PA."]
["Robert John Cornell, MD",1457331803,"75-1997880","TX","PE - Andrews County Hospital District","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-05-01","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Robert John Cornell, MD",1457331803,"26-3789190","TX","PE - Permian Physician Services","USA PPO","In Process","Application Submitted","","MQA","","2024-09-06","Submitted application via delegated roster on 8/15/2024. PA."]
["Robert John Cornell, MD",1457331803,"26-3789190","TX","PE - Permian Physician Services","United Health Care","Participating","Enrollment Complete",45294,"","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 1/3/2024.  PA"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","","Medicare","Participating","Enrollment Complete",45515,"6T6690","320497","2024-07-10","Received welcome letter. MS"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","","Omni PPO","Participating","Enrollment Complete","2024-06-10","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 6/10/2024. AS"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","BCBSTX","Participating","Enrollment Complete","2024-07-12","8WL530","","2024-07-11","Received email confirmation provider is PAR and linked to TIN/location, eff. 7/12/2024. Provider is participating with the following products: BAV - Blue Advantage HMO\nHMO - Blue Essentials\nBCA - BlueChoice PPO\nHME - Health Select\nMCH - Medicare Advantage HMO\nPMC - Medicare Advantage PPO\nWEL - WellMed MA HMO\nSNP - Dual Eligible Special Needs Plan. PA."]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2024-09-18","Approval ltr rcvd. Effective 09/18/2024. Jen Videan"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Molina","In Process","Pending Contracting","","","","2024-11-27","Emailed mhtcontractrequest@molinahealthcare.com to check the group enrollment and how to proceed with confirming the providers are active under the TIN. MS"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2024-06-28","","","2024-07-24","Approval Ltr rcvd. Effective 06/28/2024. Jen Videan"]
["Patrick M Brennan, DO",1295354264,"46-3131679","TX","","Rail Road Medicare","Participating","Enrollment Complete","2024-08-11","","","2024-08-23","Provider is active under this TIN with RR MCR. MS"]
["Laura V Salcido, PA",1669755906,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete",45432,"","","2024-09-04","Confirmed via portal, provider is linked and active. MS"]
["Laura V Salcido, PA",1669755906,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete",45432,"","","2024-07-02","Provider is Tricare  certified and linked to this location eff 5/20/24. MS"]
["Laura V Salcido, PA",1669755906,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["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","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["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","Alliance WC","Participating","Enrollment Complete",45422,"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","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-08","","","2024-04-11","Per updates@primehealthservices.com, our systems have been updated with request to add Stacy Hernandez NPI 1548026099. Effective date is contract date of 05/08/2023. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-08","","","2024-04-11","Per updates@primehealthservices.com, our systems have been updated with request to add Stacy Hernandez NPI 1548026099. Effective date is contract date of 05/08/2023. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-06-01","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","Wellmed","Participating","Enrollment Complete",45418,"","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 05/06/2024.  PA"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","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","Wellcare","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-06-14","1548026099","","2024-06-14","Approval ltr rcvd. Effective 06/14/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45457,"1548026099","","2024-06-14","Approval ltr rcvd. Effective 06/14/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-25","","","2024-07-02","Received email from Angela Bates confirming location has been added to provider’s record, eff. 06/25/2024. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete",45418,"","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted",45418,"","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-05-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  05/01/2024.  PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-10","1548026099","","2024-05-17","Please see status updates under Alliance WC payor line. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-10","1548026099","","2024-05-17","Please see status updates under Alliance WC payor line. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-05-14","","","2024-05-14","Provider enrolled at the briarwood location eff 4/30/2024. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","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 Contracting","","","","2024-05-01","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2024-05-06","","","2024-07-31","Received email confirmation provider is PAR and linked to TIN & location, eff. 05/06/2024. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 9/1/2024\n6950 Eastridge Rd,  6301 Andrews Hwy 10/4/2024.\n616 N Main St, 4705 Briarwood Ave 5/6/2024\nAS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2024-06-06","","","2024-07-31","Received email confirmation provider is PAR and linked to TIN & location, eff. 06/06/2024. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","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","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-07-30","7/30/2024 Emailed Provider_Services_Shared.T8@90degreebenefits.com and Mary Rodriguez for network status. FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete",45484,"","","2024-07-18","Received email confirmation from PPHP, provider is linked to the location/TIN, eff. 7/11/2024. PA."]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","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"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-05-06","","","","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-07-01","All locations are enrolled under the group record. MS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-07-26","","","2024-10-14","Per Dee Dee Johnson at Texas Mutual site visit completed on 07/26/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","2024-11-22","","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","2024-11-22","","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-05-06","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 5/6/2024. AS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-07-22","","","2024-07-24","Approval ltr rcvd. Effective 07/22/2024. Jen Videan"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete",45418,"","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 5/6/2024. AS"]
["Stacy J Hernandez, APRN-NP",1548026099,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-05-06","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 5/6/2024. AS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-05-06","","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2024-05-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-05-06","","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["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","United Health Care","Participating","Enrollment Complete","2024-04-26","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  04/26/2024. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. 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 Standard","Participating","Enrollment Complete","2024-04-12","","","2024-04-28","Provider is linked to all 5 locations eff 4/12/24. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","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","Participating","Enrollment Complete",45418,"","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-05-06","","","2024-06-26","As per Kodi Cox provider participating as of 5/6/2024 received via email. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-04-26","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 04/26/2024. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45441,"","","2024-08-06","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Application Submitted","","","","2024-05-15","5/15/2024 Delegated roster submitted.  FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","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","2024-05-06","8016068","","2024-06-19","6/19/2024 Spoke to Ethan S. call ref#6195709020 provider participating as of 5/6/2024. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-05-06","8016068","","2024-06-19","6/19/2024 Spoke to Ethan S. call ref#6195709020 provider participating as of 5/6/2024. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-05-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  05/01/2024.  PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-04-26","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 4/26/2024.  PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-05-06","","","2024-05-27","Received email confirmation from Christy Henson (CHenson@pphealthplan.com) provider is PAR and linked to TIN/locations, eff, 5/06/2024. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-05-06","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 5/6/2024. AS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-19","Per Galaxy rep Karen A., location add request in process. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-04-24","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",45548,"","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. Requested roster listing locations linked to provider via email. PA."]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main St., 6301 Andrews Hwy, 6950 Eastridge Rd., 4705 Briarwood Ave eff. 10/4/2024. AS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main St., 6301 Andrews Hwy, 6950 Eastridge Rd., 4705 Briarwood Ave eff. 10/4/2024. AS"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-07-30","7/30/2024 Emailed Provider_Services_Shared.T8@90degreebenefits.com and Mary Rodriguez for network status. FC"]
["Teresa L Callahan, NP",1093796435,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-04-26","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 4/26/2024.  PA"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","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","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Active","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-06-10","1093796435","","2024-06-14","Approval ltr rcvd. Effective 06/14/2024. Jen Videan"]
["Teresa L Callahan, NP",1093796435,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-06-10","1093796435","","2024-06-14","Approval ltr rcvd. Effective 06/14/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","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","Participating","Enrollment Complete","2024-06-10","","","2024-07-29","Received product roster. Provider is linked to TIN & location, eff.  06/10/2024. 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","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-07-30","7/30/2024 Emailed Provider_Services_Shared.T8@90degreebenefits.com and Mary Rodriguez for network status. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Payor Follow Up","","","","2024-07-30","7/30/2024 Emailed Provider_Services_Shared.T8@90degreebenefits.com and Mary Rodriguez for network status. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-05-10","","","2024-05-08","Received enrollment confirmation. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-29","Received email confirmation provider is par and linked to TIN/locations, eff. 07/11/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete",45629,"","","2025-01-03","Location has been added to group enrollment. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-06-10","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 6/10/2024. AS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Pending Other Enrollment","Application Resubmitted","","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-11-26","Application submitted to add this location via the Tricare portal. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","","","","2024-07-24","Providers name has been updated and is linked to Briarwood location. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","","","","2024-11-26","Provider is linked to Andrews Hwy and Main St. locations. mS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","","","","2024-11-26","Provider is linked to Andrews Hwy and Main St. locations. mS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Action Needed",45548,"","","2024-12-17","Roster has provider's last name listed as \"Ortiz\". Need to submit updated name. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",45548,"","","2024-12-17","Provider listed as par per roster dated 12/11/2024, eff. 9/13/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete",45548,"","","2024-12-17","Provider listed as par per roster dated 12/11/2024, eff. 9/13/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-06-10","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 6/10//2024. AS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-06-28","","","2024-07-26","Approval ltr rcvd. Effective 06/28/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-06-28","","","2024-07-26","Approval ltr rcvd. Effective 06/28/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Payor Follow Up","","","","2024-11-27","Submitted follow up to Ticket 2708124 for enrollment status for this location. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",45453,"","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  6/10/2024.  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","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","CAQH","Participating","CAQH Reattested",45608,"","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 7/1/2024\n6950 Eastridge Rd, 616 N Main St, 6301 Andrews Hwy, 4705 Briarwood Ave eff. 6/10/2024. AS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-04-28","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-04-26","","","2024-08-09","Welcome ltr rcvd. Effective 08/01/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","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","Participating","Enrollment Complete","2024-06-10","6324539","","2024-10-29","Received confirmation via deleagted roster from Brandy Smith Provider participating effective06/10/2024. FC"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",45453,"","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  06/10/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",45453,"","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  06/10/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45510,"","","2024-08-06","Approval ltr rcvd. Effective 08/06/2024. Jen Videan"]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",45468,"","","2024-07-02","Received email from Angela Bates confirming location has been added to provider’s record, eff. 06/25/2024. PA."]
["Olivia O Infante, APRN-FNP-BC",1447899679,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-06-28","","","2024-07-26","Please see status updates under Alliance WC payor line. Jen Videan"]
["Rizwan Asim, MD",1205287646,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","In Process","CAQH Reattested","2024-12-30","","","2024-12-30","12/30/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Rizwan Asim, MD",1205287646,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Rizwan Asim, MD",1205287646,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete",45572,"","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Kwame B Agyeman, MD",1285863753,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, effective 10/1/2024, linked to TIN & location, effective 10/1/2024."]
["Kwame B Agyeman, MD",1285863753,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Hamza Muhammad Tola, MD",1154818342,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete",45572,"","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Hamza Muhammad Tola, MD",1154818342,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete",45541,"4980702","","2024-11-25","Provider approved. MS"]
["John W Romeo, MD",1447661764,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete",45596,"","","2024-11-27","Provider is linked to this location. MS"]
["John W Romeo, MD",1447661764,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15. FC"]
["John W Romeo, MD",1447661764,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Pierre M Agnant, MD",1669868568,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested",45629,"","","2024-12-03","12/3/2024 CAQH Sweep completed pklika"]
["Pierre M Agnant, MD",1669868568,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","In Process","Payor Follow Up","","","","2024-11-27","Application is processing. MS"]
["Pierre M Agnant, MD",1669868568,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Ugochukwu Ikechi Maduforo, MD",1447630033,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-10-29","Pending MCR Approval. MS"]
["Ugochukwu Ikechi Maduforo, MD",1447630033,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2025-01-09","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff. 1/09/2025. PA."]
["Nadeem Jaffer, MD",1427302025,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15. FC"]
["Nadeem Jaffer, MD",1427302025,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15. FC"]
["Nadeem Jaffer, MD",1427302025,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","In Process","CAQH Reattested","2024-12-26","","","2024-12-26","12/26/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Nadeem Jaffer, MD",1427302025,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete",45597,"","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Sahil Batta, MD",1801324306,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete",45572,"","","2024-12-27","Received email form UHC, confirming provider is par, linked to TIN & location, eff. 10/07/2024. PA."]
["Sahil Batta, MD",1801324306,"47-5554737","TX","PE - Midland Inpatient Medical Association","Humana","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sheriffdeen O Ilo, DO",1184910382,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15. FC"]
["Sheriffdeen O Ilo, DO",1184910382,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","Participating","Enrollment Complete","2024-10-07","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  10/07/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 Profile attested"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Provider Load","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 Profile attested"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-07-02","Provider is linked to Briarwood location eff 6/13/24. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-07-02","Provider is linked to Briarwood location eff 6/13/24. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Add Info Submitted","2024-08-28","","","2024-09-17","Submitted  \"Standard Authorization, Attestation and Release\" form to BCBSTX. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Add Info Submitted","2024-08-28","","","2024-09-17","Submitted  \"Standard Authorization, Attestation and Release\" form to BCBSTX. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Add Info Submitted","2024-08-28","","","2024-09-17","Submitted  \"Standard Authorization, Attestation and Release\" form to BCBSTX. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-08-28","","","2024-09-19","Received email confirmation provider has been added to Network, under TIN/locations, eff. 8/28/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-05-21","","","2024-08-09","Welcome ltr rcvd. Effective 08/01/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC",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, APRN-FNP-BC",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, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-05-10","Q00774238","DX4335","2024-07-01","Provider has been linked to group. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-21","","","2024-10-01","Approval ltrd rcvd. Effective 08/16/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-07-18","Submitted via delegated roster on 7/15/2024. FC"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. \nLocation is linked to provider per payor website. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. \nLocation is linked to provider per payor website. PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-07-01","","","2024-10-31","Received confirmation via delegated roster provider participating as of 7/1/2024. FC"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete",45474,"","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 7/1/2024.  PA"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","Tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-05-21","","","2024-10-01","Please see status updates under Alliance WC payor line. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete",45474,"","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 7/1/2024\n616 N Main st eff. 8/1/2023\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd & 4705 Briarwood Ave eff. 8/1/2023. AS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-07-01","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 7/1/2024.  PA"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-07-01","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 7/1/2024.  PA"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","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, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",45474,"","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/01/2024.  PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-07-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  07/01/2024.  PA."]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","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, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45553,"","","2024-10-08","Approval ltr rcvd. Effective 09/18/2024. Jen Videan"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-05-22","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-05-22","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Mary Kay Ragan, APRN-FNP-BC",1366816829,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete",45474,"","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Dharti Rajesh Patel, MD",1609364777,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Dharti Rajesh Patel, MD",1609364777,"47-5554737","TX","PE - Midland Inpatient Medical Association","Rail Road Medicare","Pending Other Enrollment","Pending Info/Document","","","","2024-11-20","Pending Medicare approval. MS"]
["Dharti Rajesh Patel, MD",1609364777,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Emma E Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","Provider Load","DO NOT ENROLL","2024-06-14","","","2024-06-14",""]
["Emma E Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","CAQH","Provider Load","DO NOT ENROLL","2024-06-14","","","2024-06-14",""]
["Emma E Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Emma E Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Emma E Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","In Process","Payor Follow Up","","","","2024-11-27","Ticket 2789963. Emailed rep to review the status of the enrollment. MS"]
["Emma E 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 E 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 E Patterson, PA",1922775287,"83-0358685","TX","PE - Midland Community Healthcare Services","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, PA","Wellcare","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-05-28","","","2024-09-03","Received confirmation. MS"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","TriCare Standard","Participating","Enrollment Complete","","","","2024-11-19","Received confirmation of Triwest. I've reached back out to the provider for an effective date. MS"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, PA","Triwest VA","Participating","Enrollment Complete","2024-11-15","","","2024-11-13","Received email confirmation from Scarlett A, provider is par and linked to TIN/locations, eff. 11/15/2024. PA."]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Triwest VA","Participating","Enrollment Complete","2024-11-15","","","2024-11-13","Received email confirmation from Scarlett A, provider is par and linked to TIN/locations, eff. 11/15/2024. PA."]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Medicaid","In Process","Payor Follow Up","","","","2024-12-30","Application in PE Review. Allow up to 90 days for processing. Jen Videan"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2024-10-08","Received confirmation via email from FirstHealth provider participating eff date 8/1/2024. FC"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-05","","","2024-10-01","Received confirmation via email, provider participating as of 8/5/2024. FC"]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, PA","Galaxy Health","Participating","Enrollment Complete","2024-08-05","","","2024-09-18","Received email confirmation from Karen Avalos stating August 2024 roster has been processed. Provider is par and linked to TIN/Location, eff. 8/5/2024. PA."]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","USA PPO","Participating","Enrollment Complete","2024-08-15","","","2024-11-08","Received email confirmation from LaNetrice M,  provider is par and linked to TIN & locations, eff. 8/15/2024. PA ."]
["Audrey K Allen, APRN-FNP-C",1598517369,"75-2781652","TX","PE - West Texas Allergy, Lubbock, PLLC","Multiplan","Participating","Enrollment Complete","2024-08-05","","","2024-09-20","Received notification via email from Jessica Bess, provider participating as of 8/5/2024. FC"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete",45509,"","","2024-09-20","Received notification via email from Jessica Bess, provider participating as of 8/5/2024. FC"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Tricare Prime","Panel Closed","Panel Closed","","","","2024-07-03","This location is not Tricare credentialed, and the panel is closed at this time. Nothing further is needed. MS"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Enrollment Complete","2024-08-13","","","2024-09-30","Received confirmation via email from payor, provider participating as of 8/13/2024, FC"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Humana","Participating","Enrollment Complete","2024-10-10","","","2024-10-17","Per Humana rep, Ivy G, at 1-800-448-6262 (ref# 2000412747506 ), provider is participating, linked to TIN and both locations, eff. 10/10/2024. PA."]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","HealthSmart PPO","Participating","Enrollment Complete",45509,"","","2024-10-29","Received notification via email, provider participating as of 8/5/2024. FC"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","United Health Care","Participating","Enrollment Complete","2024-08-05","8960512","","2024-10-17","Per UHC rep Jessica, via online chat- ref# 04809568, provider is participating and linked to TIN/locations, eff. 8/05/2024. PA."]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2024-08-05","","","2024-10-04","Received confirmation via email from German Aviles, provider participating as of 8/5/2024. FC"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete","2024-08-01","","","2024-10-08","Received confirmation via email from FirstHealth provider participating eff date 8/1/2024. FC"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","CAQH","Provider Load","In House Enrollment","2024-07-02","","","2024-07-02",""]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Amerigroup","Participating","Enrollment Complete","2024-08-05","","","2024-10-01","Received confirmation via email, provider participating as of 8/5/2024. FC"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Rail Road Medicare","Participating","Enrollment Complete","2024-07-01","1144933367","CF8499","2024-09-03","Received confirmation. MS"]
["Jennifer F Blackerby, PA",1144933367,"75-2781652","TX","PE - West Texas Allergy, PA","Ambetter","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Mehboob A Rehan, MD",1952899767,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","In Process","Payor Follow Up","","","","2024-11-27","Sent status inquiry to Onboarding. MS"]
["Mehboob A Rehan, MD",1952899767,"47-5554737","TX","PE - Midland Inpatient Medical Association","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/7/2024. PA."]
["Mehboob A Rehan, MD",1952899767,"47-5554737","TX","","Superior","Participating","Enrollment Complete","2024-11-01","","","2024-01-01","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Mehboob A Rehan, MD",1952899767,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Mehboob A Rehan, MD",1952899767,"47-5554737","TX","","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Mehboob A Rehan, MD",1952899767,"47-5554737","TX","PE - Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-27","Panel is closed. MS"]
["Amanda L Marshall, MD",1518195346,"47-5554737","TX","PE - Midland Inpatient Medical Association","CAQH","Participating","CAQH Reattested","2024-11-14","","","2024-11-14","11/14/2024 CAQH Sweep completed pklika"]
["Amanda L Marshall, MD",1518195346,"47-5554737","TX","PE - Midland Inpatient Medical Association","PPHP","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["George J Germanos, MD",1144858390,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2024-11-01","2624090","","2024-11-15","Provider confirmed via email. MS"]
["George J Germanos, MD",1144858390,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2024-10-31","","","2024-11-27","Provider is linked to this location. MS"]
["George J Germanos, MD",1144858390,"47-5554737","TX","PE - Midland Inpatient Medical Association","Amerigroup","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15. FC"]
["Aliaksandr Savitski, MD",1053654863,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15. FC"]
["Aliaksandr Savitski, MD",1053654863,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2024-11-01","7A9489","519061","2024-11-06","Received approval. MS"]
["Aliaksandr Savitski, MD",1053654863,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Samantha A Hall, DPM",1942592803,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","In Process","Application Submitted","","","","2024-12-11","Submitted application via delegated roster. AS"]
["Samantha A Hall, DPM",1942592803,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","In Process","Payor Follow Up","","","","2024-11-12","Received f/u from payor. We have confirmed that your application is complete, and have forwarded it for credentialing review. Reference 13853423 MS"]
["Samantha A Hall, DPM",1942592803,"75-2656723","TX","","Alliance WC","In Process","Application Submitted","","","","",""]
["Aimel Azizi, MD",1144480997,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Aimel Azizi, MD",1144480997,"47-5554737","TX","PE - Midland Inpatient Medical Association","Scott&White (First Care)","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45652,"","","2025-01-03","Welcome ltr rcvd. Effective 12/26/2024. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-12-26","","","2025-01-03","Welcome ltr rcvd. Effective 12/26/2024. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-11-01","Q00897593","DX4335","2024-11-27",""]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","In Process","Payor Follow Up","","","","2024-12-31","Provider not yet enrolled, per UHC rep Jean via online chat ref# 04943579. Will have provider resubmitted to UHC via roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Approval ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","2024-10-04","","","2024-10-16","Application submitted via pswca.org. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","2024-10-04","","","2024-10-16","Application submitted via pswca.org. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-10-16","Please see status update under Alliance WC payor line. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-10-16","Please see status update under Alliance WC payor line. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-08","Panel is closed to any new group/locations. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-11-01","7B3481","","2024-11-14","Provider enrolled per PECOS. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-11-01","7B3481","","2024-11-14","Provider enrolled per PECOS. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete",45627,"","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-11-25","","","2024-11-22","Received welcome letter. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete",45621,"","","2024-11-22","Received welcome letter. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Triwest VA","In Process","Application Submitted","","","","2024-11-18","Submitted application via email to Scarlett A. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-10-16","","","2024-11-26","Enrollment complete for all 5 original location. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Application Submitted","2024-10-16","","","2024-11-26","Application submitted to add to Big Spring location. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-10-16","","","2024-11-26","Enrollment complete for all 5 original location. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","","","","2024-11-12","11/12/2024 Missing current liability pklika"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-16","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-10-16","This group has an active ancillary contract. No midlevels will need to be credentialed and all services are billed through the group. MS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","In Process","Payor Follow Up","","","","2024-12-31","Provider not yet enrolled, per UHC rep Jean via online chat ref# 04943579. Will have provider resubmitted to UHC via roster submission. PA."]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2024-10-16","TSCA and required documents emailed to spneast@sedgwickcms.com. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-18","Per updates@primehealthservices.com provider has been loaded. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-18","Per updates@primehealthservices.com provider has been loaded. Jen Videan"]
["Shawndra D Moore, APRN-FNP-BC",1821867714,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-17","","","2024-10-16","Received welcome letter from BCBSTX via email. Provider is participating, eff. 10/17/2024, in the following networks: Blue Advantage HMO, BlueChoice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO. PA."]
["Ashley R Smith, APRN-FNP-BC",1952134223,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Omni PPO","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Ashley R Smith, APRN-FNP-BC",1952134223,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","PPHP","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster. PA."]
["Ashley R Smith, APRN-FNP-BC",1952134223,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Mutual","In Process","Pending Info/Document","","","","2024-12-11","Texas Mutual Par Application Form and Supplemental Questionnaire emailed to Maurene McDaniel for assist in provider completing. Jen Videan"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Multiplan","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Wellmed","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster.Pending UHC enrollment. PA"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete",45617,"9443693","","2024-12-05","Received confirmation email. MS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete",45600,"","","2024-11-27","Provider is linked to all 3 location. MS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2024-11-04","","","2024-11-27","Provider is linked to all 3 location. MS"]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","In Process","Payor Follow Up","","","","2024-12-26","Enrollment pending, ref# CO-18532123. PA."]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster submission. PA."]
["Gloria A Horner, PA",1932827433,"83-0358685","TX","PE - Midland Community Healthcare Services","Superior","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024."]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","No Value Specified","Panel Closed","","","","2024-11-15","This location is not Tricare certified, and the panel is closed to new enrollments. mS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-12-11","Per updates@primehealthservices.com, provider has been added 05/23/2023. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-11-27","Roster emailed to brandhi_wilson-woods@corvel.com. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Application Submitted","","","","2024-11-15","Application submitted via email .MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","In Process","Application Submitted","","","","2024-11-15","Application submitted via email .MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-11-15","See group payor line. MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Pending Other Enrollment","Pending Medicare","","","","2024-11-15","Pending Medicare approval. MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-12-02","Emailed TSCA and required documents to . wwtxcontracts@texasmutual.com. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","In Process","Application Submitted","","","","2024-12-02","Emailed TSCA and required documents to . wwtxcontracts@texasmutual.com. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","In Process","Pending Info/Document","","","","2025-01-03","Surrogacy is still pending. MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-11-26","Please see status updates under Alliance WC payor line. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","2024-11-18","","","2024-11-26","Application submitted to add provider to Big Spring location. MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Enrollment Complete","2024-11-18","","","2024-11-26","All 5 original location are confirmed. MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","2024-11-18","","","2024-11-26","Application submitted to add provider to Big Spring location. MS"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2024-11-26","Application submitted via pswca.org. Thank you for your application. We will be in touch with you soon. Please allow at least 45 days before inquiring about the status of your application Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2024-12-02","Emailed TSCA and required documents to spneast@sedgwickcms.com. Jen Videan"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-11-25","","","2024-11-26","Received email confirming provider is PAR and linked to TIN and location, eff. 11/25/2024, participating in the following LOB's: HMO - Blue Essentials\nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nPMC - Medicare Advantage PPO. PA."]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-27","","","2024-11-27","11/27/2024 CAQH Sweep completed pklika"]
["Lee Ann Pierson, APRN-FNP-BC",1043809387,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-27","","","2024-11-27","11/27/2024 CAQH Sweep completed pklika"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","HealthSmart PPO","Participating","Re-Credentialing","2011-02-01","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.","Sedgwick","Participating","Enrollment Complete","2010-12-29","1356484497","274061759","2020-08-19","Confirmed provider is participating with WIN network in which this payor is included (list of networks attached). Kimberly Frazier"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested","2024-11-04","12124562","","2024-11-04","11/04/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Boon Chapman","Participating","Enrollment Complete",42087,"","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 3/24/2015.  DCannon"]
["James H Barnett, MD",1356484497,"27-4061759","TX","PE - Permian Cardiology Inc.","Medicare","Participating","Enrollment Complete","2011-01-27"," TXB118608","TXB115966","2020-04-22","04/22/2020 - there hasnt been any assistance fromt he group. I was able to access the providers PECOS account and confirm provider is EFF and linked to this group EFF 1-27-2011 - Stacey Hudak"]
["James H Barnett, MD",1356484497,"27-4061759","TX","","Multiplan","Participating","Re-Credentialing","2015-03-24","1356484497","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["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"]
["Pankaj J Patel, MD",1124009766,"75-2784378","TX","","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"]
["Pankaj J Patel, MD",1124009766,"75-2784378","TX","PE - Pankaj N. Patel, MD PA","Aetna","Participating","Enrollment Complete","2012-05-01","1124009766","","2020-04-15","04/15/2020 - Rec'd response from follow up team stating \"S/W Nina of Aetna @ 8003531232, provider NPI is on file for the provider and participating effective 05/01/12 under the group and TIN with delegated contract with Primed health network. Physical location is on file. Call ref# 5225848462. \" - Stacey HUdak"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2021-12-01","Q00181145","CE1588","2021-12-30","12/30/2021 Rcvd RR Medicare approval letter. RR Medicare PTAN #  Q00181145 - effective 12/1/2021.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","HealthSmart PPO","Participating","Re-Credentialing","2021-12-06","10122396","","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","","Superior","Participating","Enrollment Complete","2022-02-01","","","2022-02-07","2/7/2022 Rcvd email from Superior that provider is PAR and linked to group TIN/location effective 2/1/2022.  DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","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","","Aetna","Participating","Enrollment Complete","2021-11-15","4361906","","2021-12-29","12/29/2021 Per F/U Notes - S/W Christine of Aetna @ 8003531232, NPI# for the provider is on file, shows linked and PAR under the group and TIN# ( Individual contract ) effective 11/15/2021, the physical location is on file, The provider ID is 4361906.   DCannon"]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Omni PPO","Participating","Re-Credentialing",44536,"","","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","Boon Chapman","Participating","Re-Credentialing","2021-12-15","","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["John M McKenna, MD",1225170103,"75-2656723","TX","","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","","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["John M McKenna, MD",1225170103,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2022-01-22","8020391","","2021-11-25","11/25/21 received letter from pdmcogz@cigna.com, enrollment complete. PID 8020391 eff 1/22/2022"]
["John M McKenna, MD",1225170103,"75-2656723","TX","","Medicare","Participating","Enrollment Complete","2021-12-01","1X1311","","2021-12-08","12/8/21 Provider approved 12/01/2021. PTAN 1X1311 Cbankston"]
["Michael J Dragun, MD",1679574099,"75-2656723","TX","PE - Premier Family Care, Inc","CAQH","Provider Load","CAQH Reattested","2024-11-26","","","2024-11-26","11/26/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Michael J Dragun, MD",1679574099,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","Participating","Enrollment Complete","2024-08-01","","","2024-08-06","Provider is par, effective 8/1/2024, per the August SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Medicaid","Participating","In House Enrollment","","080363701","Unknown","2020-10-23","10/23/2020 - Rec'd email from the clinic stating \"I spoke with Swapna Patel, the office manager for Dr. Mrunal and Dr. Govind Patel. \nYes, they participate in Medicaid but they will be taking care of it themselves.\n\nTheir TPI # is 0803637-01.\n\nShe doesn’t know the effective date because they’ve had it so long.\"  - Stacey Hudak"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","TriCare Standard","Participating","Enrollment Complete",38261,"1528000734","","2020-04-06","04/06/2020 - Rec'd access to provider through payer portal and I was able to confirm provider certification with this TIN at this service location. This group is NON NETWORKED, therefore no credentialing is required. - Stacey Hudak"]
["Mrunal C Patel, MD",1528000734,"74-2348334","TX","PE - Permian Gastroenterology PA","Superior","Participating","Enrollment Complete","2020-08-01","1528000734","","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"]
["Willie Clyde Watson, III, MD",1659366433,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","Galaxy Health","Participating","Enrollment Complete","2014-09-26","1659366433","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 9/26/2014. - Jesriel Segovia"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Family Care, 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."]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2021-08-01","1103233","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Amerigroup","Participating","Enrollment Complete","2021-08-01","12731150","","2022-05-19","5/19/2022 Per roster received from Amerigroup provider is PAR and linked to group TIN effective 8/1/2021.  PID #  12731150.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","","First Health Coventry","Participating","Application Resubmitted","2021-08-01","1103233","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-29","","","2024-07-05","Per michelle.killough@pswca.org, providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website. Jen Videan"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2021-07-26","","","2023-09-08","Provider is enrolled with all locations under WesTex. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry portal. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-08-31","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main st eff. 3/1/2024\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd & 4705 Briarwood Ave eff. 6/12/2023. AS"]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","Caprock (CapStar)","Participating","Enrollment Complete","2021-01-07","","","2021-08-05","8/5/2021 Rcvd email from Caprock Provider Services provider_services_shared.t8@90degreebenefits.com  that providers from April, May and June delegated rosters have been loaded into their systems under requested TINS effective 1/7/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-01","","","2024-07-04","7/4/2024 provider participating as of 2/1/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","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","Wellmed","Participating","Enrollment Complete","2024-12-03","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff. 12/03/2024.  PA."]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","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"]
["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","IMS","Participating","Application Resubmitted","2023-10-02","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status",45629,"","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff. 12/03/2024.  PA."]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","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,"75-2656723","TX","","Caprock (CapStar)","Participating","Add Info Submitted","2021-01-07","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","","HealthSmart PPO","Participating","Enrollment Complete","2002-04-01","","","2021-04-11","4/11/2021 Rcvd email 4/11/2021 from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 4/1/2002.  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","2023-05-01","","","2023-09-02",""]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","First Health Coventry","Participating","Enrollment Complete","2020-12-01","1103233","","2022-05-11","5/11/2022 Per First Health website provider is PAR and linked to group TIN/location effective 12/1/2020.  PID # 1103233.  DCannon"]
["Lawrence A Wilson, MD",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","Gallagher","Participating","Enrollment Complete","","","","2024-02-02","Confirmed enrollment via Coventry Portal. MS"]
["Lawrence A Wilson, MD",1518951342,"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"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","Participating","Enrollment Complete","2021-07-26","","","2021-10-06","10/6/2021 Rcvd email from Karen Avalos at Galaxy confirming that the August delegated roser provider load has been completed and providers are loaded under TIN/locations effective 7/26/2021.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"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"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","","Omni PPO","Participating","Application Resubmitted","2024-02-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","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","","","","2023-10-06","4705 Briarwood and 6950 Eastridge is effective 08/01/2022. Jen Videan"]
["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,"47-3465832","TX","PE - City of Midland Health Department","CAQH","Delegated - Third Party","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - City of Midland Health Department","CAQH","Delegated - Third Party","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Delegated - Third Party","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","","Amerigroup","Participating","Add Info Submitted","2021-01-07","","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Confirm Par Status","2024-12-03","002438204","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff. 12/03/2024.  PA."]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","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"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Lawrence A Wilson, MD",1518951342,"75-6000608","TX","PE - City of Midland Health Department","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","HealthSmart PPO","Participating","Enrollment Complete","2023-05-01","","","2023-12-15","12/15/2023 Per email rcvd from Aleece Moerbe at Healthsmart provider is PAR and linked to group TIN/location effective 5/1/2023.  DCannon"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","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","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2023-09-20","","","2023-10-26","Eastridge location has been enrolled eff 10/9/23. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","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","2021-08-11","","","2024-03-22","Per BCBSTX roster, provider listed PAR, effective 8/11/2021, participating with the following networks: Blue Advantage HMO, \nBlueChoice PPO, Health Select, Blue Essentials HMO, and Medicare Advantage\nPPO. PA"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2021-08-11","","","2024-03-22","Per BCBSTX roster, provider listed PAR, effective 8/11/2021, participating with the following networks: Blue Advantage HMO, \nBlueChoice PPO, Health Select, Blue Essentials HMO, and Medicare Advantage\nPPO. PA"]
["Lawrence A Wilson, MD",1518951342,"75-2656723","TX","PE - Premier Intensive Cardiac Rehabilitation","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,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","2024-12-02","9800227","","2024-12-20","Received confirmation. MS"]
["Lawrence A Wilson, MD",1518951342,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Medicaid","Participating","Enrollment Complete","","","","2024-07-31","Approval ltr rcvd. Effective 04/05/2024. Jen Videan"]
["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","CAQH","Participating","CAQH Reattested",45600,"","","2024-11-04","11/04/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Debbie P Reese, MD",1629074984,"75-2133441","TX","PE - Midland Pediatric Associates, 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"]
["Debbie P Reese, MD",1629074984,"75-2182177","TX","PE - Debbie P. Reese, MD PA","Multiplan","Participating","Enrollment Complete","2023-12-11","","","2024-06-04","6/3/2024 Spoke to Dominique call ref#10413020, location has been added to TIN as of 12/11/2023. FC"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","","Medicare","Participating","Pending Info/Document","","","","2025-01-03","Pending surrogacy . MS"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Alliance WC","Participating","Enrollment Complete","","","","2024-09-09","Per Michelle Killough at PSWCA, provider has been active since 2016. Jen Videan"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Donald W Floyd, MD",1942216122,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Medicaid","Participating","Enrollment Complete","","","","2024-08-13","Per TMHP, Dr. Floyd is enrolled and linked to Urgent Ortho Specialists effective 11/21/2012. Jen Videan"]
["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","PE - Permian Gastroenterology PA","Medicare","Participating","Enrollment Complete","2001-08-01","83462K","00320K","2020-03-10","03/10/2020 - Signed into  PECOS and confirmed that this provider is linked to Permian Gastroenterology Pa 74-2348334 (EIN) as of 8-1-2001 - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","","HealthSmart PPO","Participating","Application Resubmitted","2011-02-01","1073555249","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","CAQH","Participating","CAQH Reattested","2024-11-05","10594793","","2024-11-05","11/05/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","","Amerigroup","Participating","Enrollment Complete",41356,"1073555249","","2020-03-19","03/19/2020 - Rec'd email from this payer (multiplan/texas true choice)  stating this provider is effective at this service location with Amerigroup - Stacey Hudak"]
["Govind B Patel, MD",1073555249,"74-2348334","TX","PE - Permian Gastroenterology PA","Aetna","Participating","Enrollment Complete",38671,"","","2024-07-22","As per Irish G call ref#6198385316, provider participating as  of 11/15/2005, listed as a PCP. I will fax a letter of intent to 855-455-8650 to update to SPEC to Aetna. FC"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete",41487,"","","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 8/1/2013.  DCannon"]
["John C Dean, MD",1013923291,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Texas Municipal League","Participating","Enrollment Complete","2016-05-27","","","2024-07-24","Please see status updates under Alliance WC payor line. Jen Videan"]
["John C Dean, MD",1013923291,"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"]
["Srikanth R Deme, MD",1124103338,"75-2949900","TX","","Aetna","Participating","Enrollment Complete","2023-10-01","1124103338","","2024-01-12","Received notice from Priscilla the provider is loaded eff 10/1/2023. MS"]
["Shylesh R Ganta, MD",1811900657,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete","2008-09-01","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","Cigna","Participating","Enrollment Complete",40391,"1811900657","","2020-04-22","04/22/2020--S/W Anna of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 08/01/2010 under the group and TIN#. Physical location is on file. Call ref# Anna04202020.\ncopied note from spreadsheet-tisha rader"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2013-01-24","1770564080","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Bhuvana Balasekaran, MD",1770564080,"46-1602172","TX","PE - Bhuvana Balasekaran, MD PA","Rail Road Medicare","Participating","Enrollment Complete","2013-04-01"," P01188488"," DT8096","2020-04-22","04/22/2020 - Verified proivder is EFF thorugh payer payer site - Stacey Hudak"]
["Eric J Venegas, MD",1760485502,"75-2930500","TX","PE - Eric J. Venegas, MD, PA","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."]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete",42736,"1295724698","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete",41372,"","","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","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2022-12-01","12/1/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","","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","","IMS","Participating","Enrollment Complete","2019-09-01","1295724698","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Enrollment Complete","2019-09-01","1295724698","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2013-04-08","1295724698","","2024-01-18","Provider is linked to this  location, but requires credentialing. MS"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2017-01-01","1295724698","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 1-1-2017 **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Kirit N Patel, MD",1295724698,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1295724698","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2023-03-26","121276305","079837301","2024-05-01","Rcvd Medicaid approval ltr. Provider effective 03/26/2023. Jen Videan"]
["Dario Beltran, MD",1912100850,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","2011-01-17","1912100850","","2021-11-15"," S/W Ella of Aetna @ 8003531232, NPI# for the provider is Linked and Par under group and TIN# effective 1/17/2011, the physical location is on file, Provider ID is 5175561. Call ref#6052978261."]
["Dario Beltran, MD",1912100850,"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."]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2016-02-09","","","2024-02-16","Per Michelle Killough @ Alliance WC provider is effective 02/19/2016.  Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website.  Jen Videan"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","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","First Health Coventry","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2020-01-01","002067277","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2020. PA"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows: \n3490 E Yukon eff. 8/31/2024\n616 N Main st eff 10/4/2024\n6301 Andrews Hwy eff 5/6/2024\n6950 Eastridge Ave & 4705 Briarwood Ave eff. 6/12/2023. AS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete",45047,"","","2023-08-17","8/17/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Terry L Beck, MD",1912991084,"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"]
["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","IMS","Participating","Application Resubmitted","2023-05-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2016-01-14","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 1/14/2016.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","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","Medicare","Participating","Enrollment Complete","2015-05-09","318466ZP5M","423838","2023-07-27","7/27/2023 Per PECOS new locations have been added to group record.  Provider is PAR and linked to group/locations effective 5/9/2015.  PID # 318466ZP5M.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","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","","","","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","IMS","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete",43831,"","","2024-07-29","Received product roster. Provider is linked to TIN & location, eff.  01/01/2020. PA."]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Coventry Workers Comp","Participating","Enrollment Complete",45200,"","","2024-01-31","Confirmed enrollment via Coventry portal. MS"]
["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","","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"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","Pending Info/Document","2024-09-18","","","2024-11-12","11/12/2024 Invalid CAQH PW pklika"]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete",45140,"","","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","Aetna","Participating","Enrollment Complete","2023-10-02","4417046","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/1/2015. FC"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024.."]
["Terry L Beck, MD",1912991084,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Enrollment Complete","2016-01-14","","","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 1/14/2016.  DCannon"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["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","","","2023-08-23","Confirmed Briarwood location is linked to provider. effective 7/28. MS"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete",45135,"","","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","Caprock (CapStar)","Participating","Enrollment Complete","2015-07-15","","","2024-03-26","Received email from Mary Rodriguez (mary.rodriguez@90degreebenefits.com) on 03/25/2024 location has been added, eff. 07/15/2015 . PA"]
["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","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","Wellmed","Participating","Confirm Par Status","2023-01-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2023. PA"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2015-09-01","","","2024-10-24","Received confirmation from Brandy Smith via roster provider is effective as of 9/1/2015. FC"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","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"]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Terry L Beck, MD",1912991084,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Boon Chapman","Participating","Enrollment Complete","2016-01-14","","","2023-12-21","12/21/2023 - Per Jessica Bess at Multiplan provider is PAR and linked to group TIN/locations effective 1/14/2016.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","In Process","Enrollment Complete","2004-10-01","1578557468","","2024-10-01","Provider is showing 207Q00000X at both locations. Jen Videan"]
["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","First Health Coventry","Participating","Add Info Submitted","2022-11-01","3637766","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","IMS","Participating","Add Info Submitted",44816,"","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2024-12-03","Received confirmation via delegated roster from Emily Starr 11/22/2024. Provider participating 11/4/2024. AS"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",44816,"","","2024-12-03","Received confirmation via delegated roster from Emily Starr 11/22/2024. Provider participating 11/4/2024. AS"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","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","2022-09-13","","","2023-05-24","Confirmed via HM portal. MS"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-09-12","","","2022-12-31","12/31/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for October has been completed.  Provider is PAR and linked to group TIN effective 9/12/2022.  DCannon"]
["Jose G Delgado, MD",1578557468,"75-2656723","TX","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","Tricare Prime","Participating","Enrollment Complete","2022-09-13","","","2024-01-25","During the Tricare audit, it was found this provider is credentialed and is in network with Tricare. MS"]
["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","Galaxy Health","Participating","Enrollment Complete","1999-04-28","1346236924","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 4/28/1999. - Jesriel Segovia"]
["Vincent P Rascon, DPM",1346236924,"91-1559006","TX","PE - Vincent P. Rascon","Caprock (CapStar)","Participating","Re-Credentialing","2012-01-01","1346236924","","2024-03-18","3/18/2024- Submitted recred status via delegated monthly roster on 3/15/2024. FC."]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Cigna","Participating","Enrollment Complete","2011-03-09","1730181389","","2020-08-26","08/26/2020 - moved to completed status after reviewing foll up complete note - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","Hartford","Delegated - Third Party","Thru Other Payor","","","","2024-01-27","Check Coventry portal for enrollment status, currently not enrolled. MS"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","PE - Andrews County Hospital District","United Health Care","Participating","Enrollment Complete","2020-06-01","1730181389","","2020-09-01","09/01/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Rand E Waddingham, M.D.",1730181389,"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"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Broadspire Services Inc.","Enrollment Stopped","Enrollment Stopped","","","","2023-10-04","Per Melody Starcher, they would like to hold off on Broadspire WC enrollment at this time. If they start to see a large amount of patients coming in with it, then they will reassess. 10/04/2023 Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Texas Mutual","Participating","Enrollment Complete","2024-06-01","1730181389","","2024-06-11","Approval ltr rcvd. Effective date 06/01/2024. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","Sedgwick","Participating","Enrollment Complete","2024-05-21","1730181389","751997880","2024-05-24","Approval ltr rcvd. Effective date 05/21/2024. Jen Videan"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","","Travelers WC","Participating","Enrollment Complete","","","","2024-02-02","Per Coventry portal provider is enrolled. Jen Videan"]
["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","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-27","Check Coventry portal for enrollment status, currently not enrolled. MS"]
["Rand E Waddingham, M.D.",1730181389,"26-3789190","TX","PE - Permian Physician Services","Amerigroup","Participating","Enrollment Complete","2012-03-01","","","2021-02-13","2/13/2021 - Rcvd complete roster from Amerigroup provider is participating and linked to TIN and location for the following plans STAR - eff 3/1/2012, MEDICARE - eff 8/1/2012, C-SNP - eff 1/1/2017, OTHER - eff 1/1/2021, OTHER - eff 1/1/2020,  PLUS - eff 3/1/2012, Star_Kids - eff 11/1/2016.  DCannon"]
["Rand E Waddingham, M.D.",1730181389,"75-1997880","TX","","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"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Caprock (CapStar)","Participating","Add Info Submitted","2012-03-01","1316965403","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","HealthSmart PPO","Participating","Add Info Submitted","2011-02-01","1316965403","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Medicare","Participating","Enrollment Complete",34792,"0059AS","N/A - no group enrollment for Medicare","2020-03-10","03/10/2020 - Signed into PECOS and found active/EFF individual provider enrollment only. No reassignment to group - Stacey Hudak"]
["Rajanikant P Pandya, MD",1316965403,"56-2697415","TX","PE - Rajanikant P. Pandya","Amerigroup","Participating","Add Info Submitted","2020-04-15","01449395","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Tricare Prime","Panel Closed","Panel Closed","","","","2021-07-09","7/9/2021 The payor is no longer extending contracts to new groups at this time; however, required to check on-line for future openings of the panel. KFrazier"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Aetna","Participating","Enrollment Complete","2009-08-17","","","2021-03-09","3/9/2021 Per \"Comform Par Status\" notes the provider is participating under the group and TIN# effective 8/17/2009, physical location is on file. Provider ID is 7900545.  DCannon"]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete",45536,"","","2024-09-01","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Cheryl J. Vallie, APRN-FNP-BC",1417941410,"20-4063608","TX","PE - C Vallie CFNP Limited Partnership","Amerigroup","Participating","Enrollment Complete",44235,"","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 2/8/2021.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","Gallagher","Participating","Enrollment Complete",43374,"","","2021-01-25","1/25/2021 - Rcvd email from payer confirming participating under tax ID and at location effectice 10/1/2018.  DCannon"]
["Joseph M Damiani, MD",1093821274,"39-9526391","TX","PE - Joseph Damiani","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,"26-3789190","TX","PE - Permian Physician Services","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, effective 10/1/2024, linked to TIN & location, effective 10/1/2024."]
["Anand C Reddy, MD",1780892760,"26-3789190","TX","","HealthSmart PPO","Participating","Enrollment Complete","2020-04-15","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 4/15/2020. AS"]
["Anand C Reddy, MD",1780892760,"81-3411343","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"]
["Anand C Reddy, MD",1780892760,"26-3789190","TX","","United Health Care","Participating","Enrollment Complete","2024-01-25","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 1/25/2024.  PA"]
["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,"26-3789190","TX","PE - Permian Physician Services","Triwest VA","In Process","Payor Follow Up","","","","2024-12-26","Sent email to payor requesting status. PA."]
["Anand C Reddy, MD",1780892760,"81-3411343","tx","PE - Permian Basin Kidney Center Inc","Amerigroup","Participating","Enrollment Complete","2020-04-15","","","2024-10-17","Provider participating with Medicaid, Star kids, Plus, PPO, effective 4/15/2020. Provider participating with Chip, Dual Medicaid Effective 7/14/2023. Provider participating with Dual Medicare, HMS SNP, ESRD effective 5/1/2022. FC"]
["Anand C Reddy, MD",1780892760,"26-3789190","TX","PE - Permian Physician Services","Wellmed","Participating","Enrollment Complete",45316,"","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 1/25/2024.  PA"]
["Anand C Reddy, MD",1780892760,"26-3789190","TX","","Amerigroup","Participating","Enrollment Complete","2024-09-13","","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 9/13/2024. AS"]
["Anand C Reddy, MD",1780892760,"26-3789190","TX","PE - Permian Physician Services","Omni PPO","Participating","Enrollment Complete","2024-01-05","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 01/25/2024. AS"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","PE - Premier Family Care, Inc","Aetna","Participating","Enrollment Complete","","","","2024-11-20","Provider is loaded to this location per the directory. MS"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","PE - Premier Family Care, Inc","PPHP","Participating","Enrollment Complete","2024-08-05","","","2024-09-17","Received email confirmation roster was processed. Provider is par and linked to TIN/location, eff. 8/5/2024. PA."]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","","Scott&White (First Care)","Participating","Enrollment Complete","2024-09-05","","","2024-09-04","Roster received from the payor. The provider is listed as PAR, effective 9/5/2024, and is linked to the TIN and location. PA."]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","","Superior","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","In Process","Enrollment Complete","2024-10-17","","","2024-11-27","Provider is linked to this location. MS"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2024-10-01","0323199","","2024-10-18","Received confirmation email. MS"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","","First Health Coventry","In Process","Application Submitted","","","","2024-11-27","Application submitted via the Aetna portal. MS"]
["Melissa D Alworth, DO",1942454525,"75-2656723","TX","","Medicaid","Pending Other Enrollment","Pending Other Enrollment","","","","2024-11-13","Pending location add to group record. In process. Jen Videan"]
["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","Wellmed","Participating","Enrollment Complete",44562,"","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","2022-11-29","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  Pediatrics specialty.\""]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete",44348,"4341928","","2021-08-27","8/27/2021 Received an email and roster from pdmcogz@cigna.com confirming practice location has been loaded to provider's record effective 6/1/2021 with assigned provider number 4341928. KFrazier"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","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","First Health Coventry","Participating","Enrollment Complete","2021-06-01","","","2021-10-13","10/13/2021  Per First Health online provider directory provider is PAR and linked to group/locations  effective 6/1/2021  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2012-10-15","","","2020-12-04","12/4/2020 - Rcvd completed PRIMED ROSTER back from the payer. This provider is PAR at this service location eff 9/1/2020.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Amerigroup","Participating","Add Info Submitted",43873,"","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Omni PPO","Participating","Add Info Submitted",44044,"","","2024-09-13",""]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","United Health Care","Participating","Enrollment Complete","2020-07-29","1093928913","","2020-08-06","8/6/2020 - Rec'd email from the payer stating \"Good news! We’ve completed the provider/group updates you requested on Jul 29, 2020 9:56:56 AM. Your request was assigned reference number PR-5410028 .\" - Stacey Hudak"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","Cigna","Participating","Enrollment Complete","2020-09-01","4341928","","2021-07-29","7/29/2021 Submitted demographic update to Intake_pdm@cigna.com on group level requesting practice location be added for provider. KFrazier"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete",41211,"","","2021-04-11","4/11/2021 Rcvd email from HealthSmart <mdipsupport@healthsmart.com> confirming participation of provider under TIN and location effective 10/29/2012.  DCannon"]
["Chandan Mazumder, MD",1093928913,"83-0358685","TX","","IMS","Participating","Enrollment Complete",44044,"","","2020-08-25","Confirmed provider is participating at this location as of 8/1/2020. Kimberly Frazier"]
["Marcy L Askins, APRN-FNP-BC",1831441385,"27-4061759","TX","PE - Permian Cardiology Inc.","Amerigroup","Participating","Add Info Submitted","2023-05-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Marcy L Askins, APRN-FNP-BC",1831441385,"27-4061759","TX","","HealthSmart PPO","Participating","Add Info Submitted","2023-05-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Marcy L Askins, APRN-FNP-BC",1831441385,"27-4061759","TX","","Multiplan","Participating","Enrollment Complete","2023-05-01","","","2023-07-25","7/25/2023 Rcvd email from Jessica Bess at Multiplan with a full roster and provider is PAR w/ group effective 5/1/2023.  DCannon"]
["Marcy L Askins, APRN-FNP-BC",1831441385,"27-4061759","TX","","IMS","Participating","Add Info Submitted","2023-05-08","","","2024-09-13","Submitted reappointment via delegated roster. FC"]
["Khadijah A. Abdurrazaq, MD",1336304120,"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"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Galaxy Health","Participating","Enrollment Complete","2020-09-17","","","2022-03-09","4/9/2022 Per roster received from Galaxy provider is listed as PAR and linked to group TIN/location effective 9/17/2020.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Aetna","Participating","Enrollment Complete","2021-06-01","","","2021-09-09","9/9/2021 Rcvd full roster from Jamie Roberts at Aetna on 9/8/2021 confirming that provider is PAR and linked to group TIN/locations effective 6/1/2021.  PID # 9132703  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Ambetter","Participating","Enrollment Complete",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."]
["Khadijah A. Abdurrazaq, MD",1336304120,"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"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2013-08-01","2424900","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2013 PID # 2424900-tisha rader"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Humana","Participating","Enrollment Complete",41515,"","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 8/29/2013.  DCannon"]
["Khadijah A. Abdurrazaq, MD",1336304120,"83-0358685","TX","PE - Midland Community Healthcare Services","Boon Chapman","Participating","Enrollment Complete",44091,"","","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","TriCare Standard","Participating","Enrollment Complete",44531,"","","2021-12-08","12/8/21 Per provider portal, provider is linked to this location. Cbankston"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","Participating","Enrollment Complete",43910,"","","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"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete",43709,"1306167309","","2020-07-27","IMS complete"]
["Maung K Hlaing, MD",1306167309,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete",44652,"","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","","USA PPO","Participating","Enrollment Complete","2023-01-09","","","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 1/9/2023.  DCannon"]
["Leo D Villaroman, MD",1073796330,"26-3413331","TX","PE - Leo Villaroman, MD, PA","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","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","PE - Leo Villaroman, MD, PA","HealthSmart PPO","Participating","Enrollment Complete","2023-01-09","","","2023-02-28","2/28/2023 Per Healthsmart website provider is PAR and loaded under TIN/location effective 1/9/2023.  DCannon"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","Superior","Participating","Enrollment Complete","2019-10-01","1306162557","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","CAQH","Participating","CAQH Reattested",45615,"","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1306162557","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","PE - Permian Cardiology Inc.","USA PPO","Participating","Enrollment Complete","2018-10-15","1306162557","274061759","2020-08-21","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Leela K Lella, MD",1306162557,"27-4061759","TX","","Multiplan","Participating","Enrollment Complete","2018-06-19","1306162557","","2020-02-12","02/12/2020 - Rec'd confirmation through payer portal stating : Provider:Leela Lella\nNetwork: MPI\nNetwork Participation effective:6/19/2018\nContract Source Group contract through DELEGATED PARTY: West Texas Physicians Alliance - Stacey Hudak"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","Amerigroup","Participating","Enrollment Complete","2020-03-18","07416220","","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"]
["Asif AK Ansari, MD",1528299872,"26-3789190","TX","","Wellmed","Participating","Enrollment Complete","2024-10-13","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 10/13/2024.  PA"]
["Asif AK Ansari, MD",1528299872,"26-3789190","TX","PE - Permian Physician Services","TriCare Standard","In Process","Payor Follow Up","","","","2024-11-27","Ticket 2790177. Submitted status request via Tricare portal. MS"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","Triwest VA","Participating","Enrollment Complete","2021-05-15","","","2021-05-31","5/31/2021 Received forwarded email from Rebecca Pontaski with confirmation provider is participating with VACCN (TriWest) effective 5/15/2021. KFrazier"]
["Asif AK Ansari, MD",1528299872,"26-3789190","TX","PE - Permian Physician Services","Cigna","In Process","Payor Follow Up","","","","2024-11-27","Sent status inquiry to Onboarding. MS"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","Omni PPO","Participating","Enrollment Complete","2019-10-01","1528299872","","2020-06-26",""]
["Asif AK Ansari, MD",1528299872,"26-3789190","TX","PE - Permian Physician Services","Superior","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & location, effective 10/1/2024.  PA."]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","","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"]
["Asif AK Ansari, MD",1528299872,"81-3411343","TX","PE - Permian Basin Kidney Center Inc","TriCare Standard","Participating","Enrollment Complete",43705,"1528299872","","2020-09-04","09/04/2020 - Rec'd access to this TIN and was able to confirm through the payer site that this provider/service location are effective and NON Networked as of 8-28-2019 - Stacey Hudak"]
["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"]
["Audrey N Mangwiro, MD",1346265162,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellmed","In Process","Application Submitted","","","","2024-11-15","Submitted application via delegated roster. Pending UHC enrollment. PA"]
["Audrey N Mangwiro, MD",1346265162,"47-5554737","TX","PE - Midland Inpatient Medical Association","TriCare Standard","Participating","Enrollment Complete","2019-12-14","","","2024-11-27","Provider is linked to this location. MS"]
["Audrey N Mangwiro, MD",1346265162,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2024-12-01","","","2024-12-19","Per December SHP validation report, provider is listed as participating, linked to TIN and location, effective 12/1/2024. PA."]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","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"]
["Alaaedin Alhomosh, MD",1063709913,"75-2656723","TX","PE - Premier Family Care, Inc","Ambetter","In Process","Application Submitted","","","","2024-12-13","Submitted add request via delegated roster submission. PA."]
["Alaaedin Alhomosh, MD",1063709913,"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"]
["Alaaedin Alhomosh, MD",1063709913,"47-5554737","TX","PE - Midland Inpatient Medical Association","Galaxy Health","Participating","Enrollment Complete","2021-01-07","","","2021-03-15","3/15/2021 Rcvd email from Michelle Monroe at Galaxy Health confirming provider is participating under TIN and at location effective 01/07/2021.  DCannon"]
["Nancy N Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-31","Panel Closed. MS"]
["Nancy N Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Cigna","Participating","Enrollment Complete","2024-12-30","8849849","","2024-11-15","Provider confirmed. MS"]
["Nancy N Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Wellcare","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Provider is par, effective 11/01/2024, per the November SHP Validation report, participating in the following lines of business: STAR, STAR PLUS, STAR HEALTH (Foster Care), Star Kids, CHIP, CHIP RSA, CHIP Perinate, Medicare Advantage, Medicare Medicaid Program (MMP), Medicare Part D, Ambetter (Commercial-Exchange). PA"]
["Nancy N Asamoa, MD",1023135639,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster 10/15/2024. FC"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-04-26","1295109510","52669: West Texas Physicians Alliance Group Cntrct","2020-02-13","02/13/2020 - Rec'd roster stating this provider is linked to DIRECT GROUP CONTRACT as of 4-26-2016. Provider is networked with Beechstreet. - Stacey Hudak"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2016-02-15","483780YPVD","0008AH","2020-03-25","03/25/2020 - Signed into providers PECOS and verified this provider is linked to our group via employer - Stacey Hudak"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete",42486,"","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 4/26/2016.  DCannon"]
["Samuel L Baumguardner, PA",1295109510,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2021-11-01","","","","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 11/1/2021.  DCannon"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Medicaid","Participating","Enrollment Complete","2016-08-15","364970901","331090601","2020-02-18","02/18/2020 - Rec'd letter from the payer stating \"Per our records shows you already enrolled using the same Medicare ID and same location under suffix\n01 revalidation date is until 06/19/2024.\"  I still have to locate this providers TPI - Stacey Hudak"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Boon Chapman","Participating","Enrollment Complete","2016-06-01","1215254156","","2020-10-05","Enrollment thru PHCS"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","TriCare Standard","Participating","Enrollment Complete","2017-03-14","1215254156","","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"]
["Jessie J Dickens, MD",1215254156,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","IMS","Participating","Re-Credentialing","2016-07-28","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","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"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Application Resubmitted","2019-08-30","1467745240","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["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","","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","","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"]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","","Triwest VA","In House Enrollment","Facility Enrollment","","","","2022-11-23","10/17/2022 - Received roster from Scarlett of TriWest VA; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Adenike T Esho, MD",1467745240,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","341837801","079837301","2024-01-18","Revalidation application approved. Effective 01/12/2023. Next revalidation due date is 05/11/2029. Jen Videan"]
["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.","Tricare Prime","Panel Closed","Panel Closed","","","","2023-05-15","5/15/2023 Tricare Prime panel is closed and currently not accepting requests to join the network.  DCannon"]
["Christopher Ryan Vela, PA",1366728909,"27-4061759","TX","PE - Permian Cardiology Inc.","Caprock (CapStar)","Participating","Application Resubmitted","2023-02-01","","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2015-10-26","1770883191","752656723","2020-08-24","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete",43831,"1770883191","","2020-07-17","7/17-2020 - Received email spreadsheet from the payor confirming that his provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Wellcare","Participating","Enrollment Complete","2022-09-01","","","2022-11-15","11/15/2022 Per roster received from Wellcare provider is PAR and linked to group TIN/location effective 9/1/2022.  DCannon"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2018-04-14","","","2020-12-21","12/21/2020 Upon review of the Self-Service portal, provider has been fully re-credentialed as it's listed as 'complete'. KFrazier"]
["Haritha Bellam, MD",1770883191,"75-2656723","TX","","Omni PPO","Participating","Enrollment Complete","2015-10-26","1770883191","","2020-06-25",""]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","","384181902","079837301","2024-02-21","Rcvd revalidation approval letter. Jen Videan"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","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","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","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","Humana","Participating","Enrollment Complete","2020-01-01","1275044422","","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"]
["Michael J Hester, APRN-AGACNP",1275044422,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-04-01","662202","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"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"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","","","2021-01-27","1/27/2021 - Rcvd email from payer showing provider as participating at location and linked to TIN effective 02/01/2011.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","First Health Coventry","Participating","Enrollment Complete","2011-09-01","1099473","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 9/1/2011 PID # 1099473\n-tisha rader"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","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","First Health Coventry","Participating","Enrollment Complete","2021-08-28","1099473","","2022-02-04","2/4/2022 Per roster received from First Health provider is PAR and linked to group TIN/location effective 8/28/2021.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","TriCare Standard","Participating","Enrollment Complete","2015-07-11","1013990761","","2020-09-24","09/24/2020 - moved to completed status after reviewing follow up complete - stacey Hudak"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Caprock (CapStar)","Participating","Enrollment Complete","2021-06-01","","","2021-08-06","8/6/2021 Rcvd email from Caprock ProviderServices.T8@90degreebenefits.com that monthly delegated roster provider load is complete and provider is loaded under TIN at location effective 6/1/2021.  DCannon"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","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"]
["Eliseo Rivera, MD",1013990761,"83-0358685","TX","PE - Midland Community Healthcare Services","Medicare","Participating","In House Enrollment","2020-08-01","TXB131681","00304W","2020-09-22","9/2/2020 - rec'd confirmation from the clinic that this service location has been added to the group enrollment.  - Stacey Hudak"]
["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,"47-5554737","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,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2020-12-19","367241202","364596201","2021-04-12","4/12/2021 Upon review of group TMHP portal, provider has been approved effective 12/19/2020 with assigned TPI 367241202. KFrazier"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","Boon Chapman","Participating","Enrollment Complete","2021-04-13","","","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 4/13/2021.   DCannon"]
["Karen Ward, APRN-NP, RNFA",1790831493,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2021-03-25","1163117","","2021-07-09","7/9/2021 Received roster from networkhelp@uhc.com confirming provider is participating under group Tax ID and location with an effective date of 3/25/2021 and assigned provider ID 1163117. KFrazier"]
["Stephen P Dodd, PA",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Stephen P Dodd, PA",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Caprock (CapStar)","Participating","Application Resubmitted","2014-08-01","1598976011","","2024-06-17","Submitted reapplication via delegated roster on 6/14/2024. FC"]
["Stephen P Dodd, PA",1598976011,"46-0950925","TX","PE - Urgent Orthopedic Specialists, PLLC","Ambetter","Participating","Enrollment Complete",44713,"","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 6/1/2022."]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2019-08-01","1437175163","","2020-07-14","07/14/2020 - Rec'd spreadsheet from the delegated team stating this provider has been linked to the PriMed contract since 8-1-2019  **see the other enrollment complete line to see details about when this provider became effective with various specific products** - stacey Hudak"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2018-09-01","716134","0008AH","2020-03-10","03/10/2020 - Signed into PECOS and confirmed that this provider is linked to Premier Family Care as an employee EFF 9-1-2018 - Stacey Hudak"]
["Nanette R Paredes, PA",1437175163,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2018-10-29","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 10/29/2018.  DCannon"]
["Frank O McGehee, IV, MD",1134151756,"27-0950535","TX","PE - McGehee Medical, PA","IMS","Participating","Enrollment Complete","2010-02-01","1134151756","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","TX","","Omni PPO","Participating","Enrollment Complete","2012-09-01","1184727562","","2020-06-29","06/29/2020 - IMS is PAR, therefore this payer is also effective  - Stacey Hudak"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","TX","PE - Premila Johnson, MD, LP","Boon Chapman","Participating","Enrollment Complete","2014-06-04","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 6/4/2014.  DCannon"]
["Premila L. S. Johnson, MD",1184727562,"90-0858471","TX","","CAQH","In House Enrollment","In House Enrollment","","","","2021-06-01","6/1/2021 Received email from Diane Faulkner the group/providers have confirmed they will process all quarterly maintence will be handled In-House. Therefore, requested they remove the PES contact information so we will no longer receive notices and pending clarification. KFrazier"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","","Aetna","Participating","Application Resubmitted","2024-02-01","","","2024-09-27"," Unable to get confirmation from Brandy or Hannah if the requested termination would be stopped. I submitted application via delegated roster on 9/27/2024. FC"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Confirm Par Status","2020-06-02","002854139","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 06/02/2020. PA."]
["Johnny L Flitton, PA",1437356730,"84-2617748","TX","PE - Midland Medicine PA","Scott&White (First Care)","Participating","Enrollment Complete","2024-06-01","","","2024-09-05","Roster received. Provider is listed par, and linked to TIN/location, eff. 06/01/2024. PA."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Application Resubmitted","2023-05-01","9326179","","2024-09-27"," Unable to get confirmation from Brandy or Hannah if the requested termination would be stopped. I submitted application via delegated roster on 9/27/2024. FC"]
["Johnny L Flitton, PA",1437356730,"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"]
["Johnny L Flitton, PA",1437356730,"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"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2015-08-28","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","TriCare Standard","Participating","Enrollment Complete","2018-06-29","1437356730","","2020-06-25","06/25/2020 - Verified this provider is participating with this group through payer portal. This group is NON NETWORKED, but this provider is certified - Stacey Hudak"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","","","","2023-09-12","Provider is active at 6950 Eastridge Rd and 4705 Briarwood Ave. Jen Videan"]
["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,"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"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2023-09-06","","","2024-01-11","1/11/2024 Per email from USA MCO - LaNetricia Myart provider is PAR and linked to group TIN/location effective 9/6/2023.  Provider is also listed on the online provider directory.  DCannon"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["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","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. 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","Confirm Par Status","2021-01-01","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 01/01/2021. PA."]
["Johnny L Flitton, PA",1437356730,"84-2617748","TX","PE - Midland Medicine PA","Wellcare","Participating","Enrollment Complete","2024-06-01","","","2024-06-04","Per SHP validation report, provider is PAR, linked to TIN and location, eff. 06/01/2024. PA."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2020-04-03","","","2024-12-26","Received email confirmation enrollment complete, eff. 4/03/2020. PA."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","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","Omni PPO","Participating","Application Resubmitted",45175,"","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Application Resubmitted","2023-09-06","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Johnny L Flitton, PA",1437356730,"84-2617748","TX","PE - Midland Medicine PA","Galaxy Health","Participating","Enrollment Complete","2024-03-08","","","2024-07-29","Received email confirmation provider is par and linked to TIN/location, eff. 03/08/2024. PA."]
["Johnny L Flitton, PA",1437356730,"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"]
["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","Caprock (CapStar)","Participating","Re-Credentialing",45175,"","","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","First Health Coventry","Participating","Application Resubmitted","2024-02-13","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024. FC"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2015-09-01","","","2020-10-30","\"10/30/2020-S/W Amanda of First Health/Coventry @ 800-937-6824, As per rep provider is in network and participating to the group and TIN# effective 09/01/2015, Physical location is on file,\ncall ref# 5701278- Rafael Calixtro\""]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete",42248,"1906310","","2023-10-23","10.23.2023 S/W Trina of First Health @ 800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 09/01/2015. Provider ID 1906310. Service location is on file. Call ref#:773486.-Danico Gabriel Melendres"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45139,"","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 08/01/2023. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete",45139,"","","2024-03-05","Per brandhi_wilson-woods@corvel.com provider is approved effective 08/01/2023. Jen Videan"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete",45566,"","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 10/4/2024. AS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 5/6/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 6/12/2023\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 10/4/2024. AS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Zurich","Delegated - Third Party","Thru Other Payor","","","","2024-01-30","Check Coventry portal for enrollment updates. MS"]
["Johnny L Flitton, PA",1437356730,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"12235261","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Johnny L Flitton, PA",1437356730,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested",45608,"12235261","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","Cigna","Participating","Enrollment Complete",42605,"1912068446","","2020-02-20","02/20/2020 - Payer confirmed that this provider is EFF as of 8-23-2016 at this service location under a DIRECT CONTRACT with this payer - Stacey Hudak"]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","PE - Midland Inpatient Medical Association","Aetna","Participating","Re-Credentialing",44044,"1912068446","","2024-02-20","2/20/2024- Submitted recred status via delegated monthly roster on 2/15/2024. FC."]
["Allen E Gibson, MD",1912068446,"47-5554737","TX","","Humana","Participating","Re-Credentialing","2020-01-01","1912068446","","2024-02-19","2/19/2024 - submitted recred status via delegated monthly roster on 02/15/2024. PA."]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","Liberty Mutual","Participating","Enrollment Complete",40109,"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","","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","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete",40575,"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",40441,"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","","Humana","Participating","Enrollment Complete",43831,"","","2021-11-18","11/18/2021 Rcvd full roster from Humana listing provider as PAR and linked to group TIN/location effective 1/1/2020.  DCannon"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","","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"]
["Gerardo M Catalasan, MD",1760501720,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",40109,"1760501720","752656723","2020-08-26","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2008-11-01","P00716501","","","3/25/2020--3/25/2020-Per online check, provider is now PAR effective 11/01/2008 with provider number P00716501. Attached welcome letter to payor line.-Elonah Grace B.Gelig"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2020-01-01","1093937948","","2020-07-16","7/16/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Superior","Participating","Enrollment Complete",42736,"1093937948","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete",43258,"1093937948","Permian Basin Healthcare Network","2020-09-24","09/24/2020 - moved to enrollment complete. Networked with: Multiplan/PHCS/BeechStreet\nunder  delegated group, Permian Basin Health.   - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Sedgwick","Participating","Enrollment Complete",40109,"","","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","Tricare Prime","Participating","Enrollment Complete",44126,"","","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","Boon Chapman","Participating","Enrollment Complete",43258,"","","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 6/7/2018.  DCannon"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","Medicare","Participating","Enrollment Complete",39753,"8L6420","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete",40109,"","","2020-09-09","Confirmed provider is participating with PPO, H&W and WIN networks (list of networks attached). Kimberly Frazier"]
["Nikolay A Azarov, MD",1093937948,"75-2656723","TX","","IMS","Participating","Enrollment Complete",43709,"1093937948","","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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Liberty Mutual","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 submission. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","BCBSTX","In Process","Payor Follow Up","","","","2024-12-31"," Sent email to payor requesting status. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","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","","","","2024-11-14","Per Michelle Killough at michelle.killough@pswca.org location has been added to group profile. Providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-10-16","No updates are needed at the individual level for RR MCR when adding a new location unless that location will be updated to the primary location. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Texas Mutual","Participating","Enrollment Complete","2024-07-26","","","2024-10-14","Per Dee Dee Johnson at Texas Mutual site visit completed on 07/26/2024. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Tricare Prime","Panel Closed","Panel Closed","","","","2024-11-26",""]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","United Health Care","Participating","Enrollment Complete","2020-08-22","","","2024-12-30","Received email confirming provider has been added to the network, linked to TIN & location, eff. 08/22/2020. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-18","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"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."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Facility Enrollment","Enrollment Complete","2016-06-01","1376723361","47-3465832","2020-06-16","06/16/2020 - CIGNA has an ancillary contract in place for this WesTex Urgent Care (as an urgent care center) that's EFF 6-1-2016.\nPer payer, each provider does not need to be credentialed as long as the facility and service location is on file. I confirmed that all service locations are linked to group contract (1941 E 37th St, 210 W Longview Ave & 3401 Gerenbriar Ste 200) - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2020-01-30","1376723361","","2020-06-25","06/25/2020 - Verified this provider is participating with this group through payer portal. This group is NON NETWORKED, but this provider is certified - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","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","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","","Scott&White (First Care)","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2020-08-22","003026419","","2023-11-17","11/17/2023 Per email rcvd from UHC provider is PAR and linked to group TIN and location effective 8/22/2020.  MPIN # 003026419.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2018-11-30","1376723361","","2020-03-03","03/03/2020 - Rec'd confirmation of provider enrollment through payer portal.  - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","13780299","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","13780299","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Jeffrey Limbacher, PA-C",1376723361,"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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","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"]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Multiplan","Participating","Enrollment Complete","2022-01-03","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 1/3/2022.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Multiplan","Opt Out","Payor Follow Up","","","","2024-04-30","Sent email to Multiplan rep Marcie Havens (marcie.havens@multiplan.com) requesting enrollment status update. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"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 #6192822735 616 N Main participating as of 2/1/2024. FC"]
["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","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","","","","2024-11-14","Please see status updates under Alliance WC payor line. Jen Videan"]
["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","","","2023-11-05","Provider is linked to Andrews Hwy location eff 10/26/23. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Boon Chapman","Thru Other Payor","Pending Other Enrollment","","","","2024-01-12","1/12/2024 Pending Multiplan enrollment.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","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"]
["Jeffrey Limbacher, PA-C",1376723361,"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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-11-26","Application submitted to add this location via the Tricare portal. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","Participating","Enrollment Complete","2023-05-01","","","2023-09-04","9/4/2023 Received email from Scott & White HPDELEGATION@BSWHealth.org that provider load from May has been completed and provider is PAR effective 5/1/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-05-29","","","2024-07-05","Per michelle.killough@pswca.org, providers are paid via tax ID number, so they are paid no matter what location they provide services from.  The Alliance will only list two locations per provider on our website. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Sedgwick","Participating","Enrollment Complete",45343,"","","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","Rail Road Medicare","Participating","Enrollment Complete","2017-09-06","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","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2017-09-06","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","","","2024-07-30","Received product roster. Provider is PAR and linked to TIN & location, eff. 08/22/2020. PA"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-05-29","","","2024-08-06","Per brandhi_wilson-woods@corvel.com location has been added. Original contract effective date 07/20/2020. Jen Videan"]
["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","","","",45318,"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","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2014-11-28","","","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","","Broadspire Services Inc.","In Process","Application Submitted","","","","2024-11-27","Roster emailed to updates@primehealthservices.com. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete",42803,"","","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","","PPHP","Participating","Enrollment Complete","2024-07-11","","","2024-07-17","Received email confirmation from PPHP, provider is linked to the location/TIN, eff. 7/11/2024. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","","Ambetter","In Process","Payor Follow Up","2022-04-01","","","2024-11-12","Requested enrollment status under TIN/location, sent to SHP delegation. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"75-2656723","TX","PE - Premier Family Care, Inc","HealthSmart PPO","Participating","Enrollment Complete","2016-07-25","13512484","","2020-07-21","07/21/2020 - rec'd spreadsheet from the payer stating this provider/TIN/service location is EFF - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","IMS","Participating","Enrollment Complete","2019-09-01","1376723361","","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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Medicare","Participating","Enrollment Complete","2017-09-01","615599ZP5M","","2020-06-15","06/15/2020 - Rec'd spreadsheet from the clinic stating this proivder is EFF - Stacey Hudak"]
["Jeffrey Limbacher, PA-C",1376723361,"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"]
["Jeffrey Limbacher, PA-C",1376723361,"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."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Gallagher","Delegated - Third Party","Add to Next Delegated Roster","","","",45318,"Provider is not listed on the Coventry portal. Please add to next delegated roster. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","Rail Road Medicare","Participating","Enrollment Complete","2017-09-06","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","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","Texas Municipal League","Participating","Enrollment Complete","2024-05-29","","","2024-07-05","Please see status updates under Alliance WC payor line. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","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","Broadspire Services Inc.","Participating","Enrollment Complete","2023-05-23","","","2024-02-09","Per Broadspire directory provider has been added to TIN. Contract effective date 05/23/2023. Jen Videan"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","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"]
["Jeffrey Limbacher, PA-C",1376723361,"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"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-06-25","","","2024-07-02","Received email from Angela Bates confirming location has been added to provider’s record, eff. 06/25/2024. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-07-01","","","2024-06-28","Group enrollment has been approved and this location has been linked and is active effective 7/1/2024. MS"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","HealthSmart PPO","Participating","Enrollment Complete","2024-02-01","","","2024-07-04","7/4/2024 provider participating as of 2/1/2024 as per Aleece Moerbe from HealthSmart via email confirmation. FC"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","","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","","Humana","Participating","Enrollment Complete","2017-11-30","","","2023-09-15","9/15/2023 Per email received from Humana provider is PAR and linked to group TIN/locations effective 11/30/2017.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","tx","","Boon Chapman","Participating","Enrollment Complete","2023-10-02","","","2023-09-20","9/20/2023 Per email received from Jessica Bess at Multiplan August roster has been completed.  Provider is PAR and linked to group TIN/location effective 10/2/2023.  DCannon"]
["Jeffrey Limbacher, PA-C",1376723361,"47-3465832","TX","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"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Galaxy Health","Participating","Enrollment Complete","2008-04-09","1790972610","","2020-07-17","7/17/2020 - Received a spreadsheet from the payer stating this provider is effective as of 4/9/2008 - Jesriel Segovia"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","Caprock (CapStar)","Participating","Enrollment Complete","2012-03-01","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","Cigna","Participating","Enrollment Complete","2010-11-18","1790972610","","2020-04-22","04/22/2020--S/W Rica of Cigna @ 8008824462, provider NPI# is on file for the provider and is participating effective 11/18/2010 under the group and TIN#. Physical location is on file. Call ref# Rica04202020.\ncopied note from spreadsheet-tisha rader"]
["Sapna Chilka, MD",1790972610,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","First Health Coventry","Participating","Enrollment Complete","2010-12-01","1621807","","2020-02-25","03/20/2020 - Rec'd an email from the payer stating this provider is EFF under this TIN. Email shared provider ID# 1621807 - Stacey Hudak"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","United Health Care","Participating","Enrollment Complete","2020-04-12","3345549","","2020-07-30","7/30/2020 - moved to completed status after reviewing follow up complete note - Stacey Hudak"]
["Ajay K Vaikuntam, MD",1447415476,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","Participating","Re-Credentialing","2019-09-01","1447415476","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Wayne L Sager, MD",1225182314,"75-2133441","TX","PE - Midland Pediatric Associates, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2011-02-01","1225182314","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","USA PPO","Participating","Enrollment Complete","2019-01-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Tareq Hulali, MD",1194813709,"90-0956632","TX","PE - Tareq Hulali, MD LLLP","Omni PPO","Participating","Enrollment Complete","2019-01-21","1194813709","","2020-06-25",""]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc DUPE","TriCare Standard","Participating","Enrollment Complete","2024-05-31","","","2024-06-28","Provider has been linked to this location eff 5/31/24. MS"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-07-24","RR MCR does not add more than 1 location to their group record. They only need notified if the new location is replacing the main location on the record. MS"]
["Adriana E Nur, MD",1619982584,"75-2656723","TX","PE - Premier Family Care, Inc DUPE","Caprock (CapStar)","Participating","Enrollment Complete","2017-11-29","","","2024-10-07","Received confirmation via email, provider participating effective 11/29/2017. FC"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","","Rail Road Medicare","Participating","Enrollment Complete","2024-01-01","Q00724435","","2024-04-24","Confirmed enrollment eff 1/1/24. MS"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","PE - Premier Family Care, Inc","Scott&White (First Care)","Participating","Enrollment Complete","2024-01-18","","","2024-01-08","1/8/2024 Rcvd email from Scott & White that provider is PAR and linked to group TIN/location effective 1/18/2024.  DCannon"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","","Wellmed","Participating","Enrollment Complete","2024-02-05","","","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","","Aetna","Participating","Enrollment Complete","2023-12-04","","","2024-03-06","Confirmed provider is enrolled effective 12/4/2023. Ref# 6184671479. MS"]
["Shailesh Jain, MD",1215922802,"75-2656723","TX","","IMS","Participating","Enrollment Complete","2023-12-04","","","2024-01-02","1/2/2024 Rcvd email from German Avilies at IMS/OMNI that December delegation roster is complete.  Provider is PAR and linked to group TIN/location effective 12/4/2023.  DCannon"]
["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","First Health Coventry","Participating","Enrollment Complete","2011-08-01","1101456","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2011 PID # 1101456-tisha rader"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Medicaid","Participating","Enrollment Complete","2009-12-07","147713503","079837301","2020-12-15","12/15/2020 Upon review of TMHP portal and per email forwarded from Candace Wynne, provider's revalidation is complete and will be due for revalidatio 12/13/2025. KFrazier"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2011-09-06","P01465345","","2020-03-25","3/25/2020--\"\n3/25/2020-Per online check, provider is now PAR effective 09/06/2011 with provider number P01465345. Attached welcome letter to payor line.-Elonah Grace B.Gelig \""]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2011-09-01","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-01-08","1376556019","","2020-09-08","09/08/2020 - reviewed previous note and moved to completed status - Stacey Hudak"]
["Staton Awtrey, MD",1376556019,"75-2656723","TX","PE - Premier Family Care, Inc","TriCare Standard","Participating","Enrollment Complete","2024-02-13","1376556019","","2024-02-29","Provider is linked to this location. MS"]
["Juan C Gil, MD",1558392779,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Re-Credentialing","2012-01-01","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","2010-06-06","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","Wellmed","Participating","Enrollment Complete","2022-01-01","","","2023-03-23","3/23/2023 Rcvd roster from UHC w/ all Wellmed participating providers.  Provider is PAR effective 1/1/2022.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Sedgwick","Participating","Enrollment Complete","2024-06-19","1174846364","","2024-06-28","Approval ltr rcvd. Provider effective 06/19/2024. Jen Videan"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","First Health Coventry","Participating","Enrollment Complete","2020-03-20","","","2022-04-26","4/26/2022 Per First Health provider directory provider is PAR and linked to group TIN/location.  DCannon"]
["Rebecca A Sanchez, PA",1174846364,"46-3131679","TX","PE - Midland Texas Orthopedic Group Inc","Alliance WC","Participating","Enrollment Complete","2022-11-18","","","2024-09-10","Welcome ltr rcvd. Effective 11/18/2022. Jen Videan"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Wellmed","Terminated","Terminated","2022-01-01","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","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete","2010-08-01","1945548","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2010 PID # 1945548-tisha rader"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","First Health Coventry","Participating","Enrollment Complete","2010-08-01","1945548","","2020-03-20","3/20/2020-receieved email with roster stating provider PAR 8/1/2010 PID # 1945548-tisha rader"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2010-07-14","1881711778","","2020-06-22","06/22/2020- Rec'd email from the payer confirming this provider is PAR with this group/service location - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Amerigroup","Participating","Add Info Submitted","2020-04-15","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Boon Chapman","Participating","Enrollment Complete","2020-07-02","1881711778","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 7/2/2020.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","Ambetter","Participating","Enrollment Complete","2022-04-01","1881711778","","2022-06-13","6/13/2022 Per roster received from Superior provider is PAR and linked to group delegation roster effective 4/1/2022."]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Multiplan","Participating","Enrollment Complete","2021-08-13","1881711778","","2021-09-15","9/15/2021 Received welcome letter from Multiplan listing provider has PAR under group TIN/location effective 8/13/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Galaxy Health","Participating","Enrollment Complete","2019-09-01","1881711778","","2020-08-24","08/21/2020 - Rec'd email confirmation that this roster was processed and this provider was made effective with the requested eff date of 9-1-2019 - Stacey Hudak"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Omni PPO","Participating","Add Info Submitted","2010-07-14","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Caprock (CapStar)","Participating","Add Info Submitted","2012-03-01","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","IMS","Participating","Enrollment Complete","2021-08-02","1881711778","","2021-09-24","9/24/2021 Rcvd email from German Aviles at IMS/OMNI that delegation roster for July & August have been completed and updated in their system effective 8/2/2021.  DCannon"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","HealthSmart PPO","Participating","Add Info Submitted","2011-02-01","1881711778","","2024-08-19","Submitted reapplication via delegated roster on 8/15/2024. FC"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","PE - West Texas Allergy, PA","Medicaid","Participating","Enrollment Complete","2010-07-25","1881711778","","2023-12-14","Michael Wolbert NPI is a performing provider of the group for any location of the group. Jen Videan"]
["Michael P Wolbert, MD",1881711778,"75-2781652","TX","","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","USA PPO","Participating","Enrollment Complete","2014-06-02","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Ayodele Olowookere, MD",1124350442,"49-4110931","TX","PE - Ayodele O Olowookere MD, PA","TriCare Standard","Participating","Enrollment Complete","2014-06-17","","","2022-07-20","7/20/2022 Per Tricare portal provider is PAR and linked to group TIN/location effective 6/17/2014.  DCannon"]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","Amerigroup","Participating","Re-Credentialing","2012-03-01","1487837712","","2024-05-16","5/16/2024- Submitted recred status via delegated monthly roster on 5/15/2024. FC."]
["Rosanna Y Catalasan, MD",1487837712,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2010-01-01","8L23968","0008AH","2020-01-29","01/29/2020 - confirmed EFF through PECOS group enrollment - Stacey Hudak"]
["Aaron B Stike, MD",1366652315,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2024-08-08","","","2024-11-06","Received product roster from UHC. Provider is listed as PAR, linked to TIN & location, eff. 08/08/2024. PA."]
["Aaron B Stike, MD",1366652315,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2024-08-08","","","2024-09-18","Received email confirmation provider is PAR, and linked to TIN/location, eff. 8/8/2024. PA."]
["Aaron B Stike, MD",1366652315,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2024-08-15","","","2025-01-03","Received email confirmation provider is par and linked to TIN/location, eff. 08/15/2024. PA."]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","USA PPO","Participating","Enrollment Complete","2016-10-26","","","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","Galaxy Health","Participating","Enrollment Complete","2022-07-01","","","2022-10-15","10/15/2022 Per follow-up email from KAvalos at Galaxy August delegation roster has been completed and provider is PAR and linked to group effective 7/1/2022.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-03-02","","","2022-03-09","3/9/2022 Per Tricare portal provider is certified and linked to location as of 3/2/2022. Cbankston"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","United Health Care","Participating","Enrollment Complete","2020-03-20","","","2022-08-01","8/1/2022 Rcvd email from UHC that provider is PAR and linked to group/location effective 3/20.2020.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2016-07-08","1437402278","","2020-07-10","07/10/2020 - updated payer line to enrollment complete status instead of \"Delegated status\" for report running purposes - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Multiplan","Participating","Enrollment Complete","2016-01-27","1437402278","Permian Basin Healthcare Network","2020-09-28","09/28/2020 - Rec'd spreadsheet from the payer stating this provider is EFF through: Permian Basin Healthcare Network with the following networks: Multiplan/PHCS/BeechStreet - Stacey Hudak"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Medicare","Participating","Enrollment Complete","2016-03-21","","","2022-07-21","7/21/2022 Per PECOS provider is PAR and linked to group PTAN.  Ind PTAN # 299111YPVD - effective 3/21/2016.  DCannon"]
["Matthew A Sanchez, APRN-NP",1437402278,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-07-01","","","2022-11-15","11/15/2022 Per email rcvd from Vernita Young at Humana delegated roster provider load for August is complete.  Provider is PAR and linked to group TIN/locations effective 7/1/2022.  DCannon"]
["Viktor Miro, MD",1073856019,"47-5554737","TX","PE - Midland Inpatient Medical Association","Tricare Prime","Panel Closed","Panel Closed","","","","2024-10-31","Panel Closed. MS"]
["Viktor Miro, MD",1073856019,"47-5554737","TX","PE - Midland Inpatient Medical Association","Multiplan","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Viktor Miro, MD",1073856019,"47-5554737","TX","PE - Midland Inpatient Medical Association","IMS","In Process","Application Submitted","","","","2024-11-14","Submitted application via delegated roster. AS"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2022-12-01","Q00375443","CE1588","2022-11-30","11/30/2022 Rcvd RR Medicare approval letter.  PTAN # Q00375443 - effective 12/1/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","","USA PPO","Participating","Enrollment Complete","2024-06-15","","","2024-10-21","Received email from LaNetrice M. confirming provider is PAR, linked to TIN & location,  eff. 6/15/2024; phone and fax # updated. PA."]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","","TriCare Standard","Participating","Enrollment Complete","2022-09-14","","","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"]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","PE - Delight Pediatrics","Wellmed","In Process","Thru Other Payor","","","","2024-12-10","Pending UHC enrollment. PA"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Galaxy Health","Participating","Enrollment Complete","2022-10-10","","","2022-12-31","12/31/2022 Rcvd email from Karen Avalos at Galaxy that delegated roster submission for October has been completed.  Provider is PAR and linked to group TIN effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","PE - Delight Pediatrics","Ambetter","Participating","Enrollment Complete","2024-09-01","","","2024-09-18","Received Sept Validation report from SHPDelegation. Provider is listed par and linked to TIN/location, eff. 9/1/2024. PA."]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","","United Health Care","In Process","Pending Contracting","2024-06-07","","","2024-12-10","Per UnitedHealthcare representative Shirley (via online chat, reference #04908674), the TIN is not yet contracted. A request has been submitted under PR-8723280 to have the contract sent to the provider/group. The representative indicated a turnaround time of 30-45 business days for this request to be processed but recommended checking back next week for any updates. The provider's email addresses have been provided to UHC. PA."]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Humana","Participating","Enrollment Complete","2022-10-10","","","2023-02-17","2/17/2023 Per email received from Priscilla Albertine at MQA she received confirmation from Humana that provider is PAR and linked to group TIN/location effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2022-10-10","","","2023-09-01","9/1/2023 Per email received from Multiplan provider is PAR and linked to group TIN/locations effective 10/10/2022.  DCannon"]
["Mohammed H Aljarwi, MD",1013320050,"92-0675116","TX","PE - Delight Pediatrics","Cigna","Enrollment on Hold","Application Submitted","","","","2024-07-23","Application submitted via email to Medical Onboarding. MS"]
["Mohammed H Aljarwi, MD",1013320050,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2022-09-14","","","2024-01-25","Confirmed provider is credentialed and in network with Tricare. MS"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","USA PPO","Participating","Enrollment Complete","2021-06-01","","","2021-08-04","8/4/2021  In following up with USAMCO (800-872-3860) I was told that you can confirm participating via the USA MCO website  https://providersearch.usamco.com/hwprovsearch.  Provider is PAR and linked to location/TIN effective 6/12021.  DCannon"]
["Michael T Caglia, MD",1568789550,"85-3162122","TX","PE - Basin Dermatology","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","Amerigroup","Enrollment Stopped","Enrollment Stopped","","","","2021-08-05","8/5/2021 Provider will not be accepting Medicaid therefore, Amerigroup enrollment will not be persued.  DCannon"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Caprock (CapStar)","Participating","Enrollment Complete","2016-10-05","1619008141","","2020-06-02","06/02/2020 - rec'd spreadsheet back from the payer Mary Rodriguez <MRodriguez@caprockhp.com> confirming this provider/service location is EFF with this payer - Stacey Hudak"]
["Joan S R Petalcorin, MD",1619008141,"75-2656723","TX","PE - Premier Family Care, Inc","Boon Chapman","Participating","Enrollment Complete","2016-10-12","","","2021-08-06","8/6/2021 Boon Chapman falls under the Multiplan umbrella, received roster from Multiplan provider is listed on roster under TIN/location as PAR effective 10/12/2016.  DCannon"]
["Joan S R Petalcorin, MD",1619008141,"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"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","HealthSmart PPO","Participating","Enrollment Complete","2012-09-26","1093935975","","2020-06-04","06/04/2020 - Rec'd email from the payer stating this provider is EFF - Stacey Hudak"]
["Alim M Ladha, MD",1093935975,"45-3020135","TX","PE - Alim M. Ladha, MD","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1093935975","","",""]
["Leela Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Triwest VA","In House Enrollment","In House Enrollment","","","","2022-02-23",""]
["Leela Sharath Pillarisetty, MD",1235484114,"86-3825791","TX","PE - West Texas Ob/Gyn","Scott&White (First Care)","Participating","Enrollment Complete","2022-02-15","","","2022-05-05","5/5/2022 Rcvd email from Scott & White confirming that the February delegation roster has been completed and the provider are now loaded and PAR w/ group TIN/locations effective 2/15/2022.  DCannon"]
["Leela 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","Boon Chapman","Participating","Enrollment Complete","2017-09-01","","","2022-03-10","3/10/2022 Rcvd roster from Multiplan listing provider as PAR and listed under group TIN/location effective 9/1/2017.  DCannon"]
["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","Humana","Participating","Enrollment Complete","2020-01-01","1871782961","","2020-07-15","7/15/2020 - Received email spreadsheet from the payor confirming that this provider is EFF at this service location and PAR with the PRIMED DELEGATED agreement - Pam Porter"]
["Anju B Varanasi, MD",1407070162,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","In Process","Payor Follow Up","","","","2024-12-31","Application in PE Review status. Jen Videan"]
["Anju B Varanasi, MD",1407070162,"47-5554737","TX","","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, effective 10/1/2024, linked to TIN & location, effective 10/1/2024."]
["Anju B Varanasi, MD",1407070162,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. PA."]
["Anju B Varanasi, MD",1407070162,"47-5554737","TX","","IMS","Participating","Enrollment Complete","2024-09-09","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 9/9/2024. AS"]
["Anju B Varanasi, MD",1407070162,"47-5554737","TX","","Tricare Prime","Panel Closed","Panel Closed","","","","2024-08-12","Location is not Tricare credentialed, and the panel is closed to new enrollment. MS"]
["Anju B Varanasi, MD",1407070162,"47-5554737","TX","PE - Midland Inpatient Medical Association","HealthSmart PPO","Participating","Enrollment Complete","2024-09-09","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 9/9/2024. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-25","Per UHC rep Jeevanantham via online chat: \"The requested provider is having an active contract under the respective TIN with an effective date of 10/07/2024.\" PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-06-07","","","2024-08-30","Approval Ltr rcvd. Effective 09/01/2024. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-07-17","Submitted via delegated roster on 7/15/2024. FC"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-07-17","Submitted via delegated roster on 7/15/2024. FC"]
["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","Amerigroup","Participating","Enrollment Complete","2024-07-01","","","2024-11-11","Received confirmation via delegated roster. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Participating","Enrollment Complete","2024-08-16","","","2024-09-19","Please see status updates under Alliance WC payor line. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-07","Received confirmation via email from Emily Starr. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","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","Ambetter","Participating","Enrollment Complete","2024-11-01","","","2024-11-08","Location addition (5514 N Big Spring) completed, effective November 1, 2024, as per the November SHP Validation report. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","Participating","Enrollment Complete","2024-07-01","","","2024-12-31","Received email confirming provider has been added to the network, linked to TIN & location, eff.  7/1/2024.  PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Enrollment Stopped","Application Submitted","","","","2024-07-17","Submitted via delegated roster on 7/15/2024. FC"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-01","Q00774595","DX4335","2024-07-01","Provider has been approved. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","2024-06-01","Q00774595","DX4335","2024-07-01","Provider has been approved. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Participating","Enrollment Complete","2024-09-18","","","2024-10-08","Approval ltr rcvd, Effective 09/18/2024. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-07-01","","","2024-11-13","Received confirmation from German Aviles via email. Provider participating as of 7/1/2024. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-10","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-06-10","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Alliance WC","Participating","Enrollment Complete","2024-08-16","","","2024-09-19","Rcvd approval ltr. Effective 08/16/2024. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Payor Follow Up","","","","2024-11-12","Emailed FirstHealth to get an update on provider's network status. AS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email confirmation provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-07-14","","","2024-07-29","Received email confirmation provider is par and linked to TIN/locations, eff. 07/14/2024. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-07-01","","","2024-10-31","Received confirmation via delegated roster provider participating as of 7/1/2024. FC"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","In Process","Application Submitted","","","","2024-11-27","Roster emailed to updates@primehealthservices.com. Jen Videan"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Participating","Enrollment Complete","2024-08-06","","","2024-08-06","Approval ltr rcvd. Effective 08/06/2024. Jen Videan"]
["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","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","Participating","Enrollment Complete","2024-06-10","","","2024-10-02","Provider is linked to the Eastridge location. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-06-10","","","2024-10-02","Provider is linked to the Eastridge location. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-06-10","","","2024-11-26","Provider is linked to all 5 locations. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","Participating","Enrollment Complete","2024-06-10","","","2024-10-02","Provider is linked to the Eastridge location. MS"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. \nLocation is linked to provider per payor website. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. \nLocation is linked to provider per payor website. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","Participating","Enrollment Complete","2024-09-13","","","2024-12-17","Per payor roster dated 12/11/2024, provider is listed par, eff. 9/13/2024. \nLocation is linked to provider per payor website. PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2023-06-13","","","2024-09-12","Received email confirmation from BCBSTX, provider is par, eff. 6/13/2024, and linked to TIN/locations. Provider is participating in the following LOB's: •       Blue Choice PPO: 06/21/2024\n•       Blue Advantage HMO: 06/21/2024 \n•       Blue Essentials HMO: 06/21/2024 \n•       Health Select: 06/21/2024 \n•       Medicare Advantage PPO: 06/21/2024 \n•       TriWest T5 TriCare Program: 01/01/2025 . PA."]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Henry B Sirengo, RN, FNP-BC",1285175927,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-10-07","","","2024-12-27","Received email confirming provider has been added to the network, linked to TIN & location, eff.  10/07/2024.  PA."]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","PE - Premier Family Care, Inc","Cigna","Participating","Enrollment Complete","2021-07-06","6423215","","2021-07-07","7/7/2021 Received an email from discovercigna@information.cigna.com confirming provider is participating under group Tax ID effective 7/6/2021 with assigned provider number 6423215. KFrazier"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","","Omni PPO","Participating","Application Resubmitted","2019-05-21","1053601344","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tiffany D Cossey, MD",1053601344,"75-2656723","TX","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.\""]
["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","","Scott&White (First Care)","Participating","Enrollment Complete","2019-07-29","1972816189","","2020-08-19","08/19/2020 - Rec'd response from the payer stating this provider is affiliated with the PRIMED DELEGATED AGREEMENT under this TIN/Service Location. This provider is networked with: \nFirstCare MyChoice PPO\nCHIP\nFirstCare Select Benefit Network\nHMO Enhanced Benefit Network\nMedicaid (FC)\nMedicare (FC)\nPPO Limited Benefit Network\n- Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","PE - Permian Cardiology Inc.","Triwest VA","Facility Enrollment","Facility Enrollment","","","","2022-10-17","10/17/2022 - Received roster from Scarlett; provider status: \"No Action.  TIN is CCN participating under own DCN.\""]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","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"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","TriCare Standard","Participating","Enrollment Complete","2017-09-01","1972816189","","2020-03-10","03/10/2020 - Signed onto payer portal and found this provider is linked to the group at this service location. Please note that this TIN is OUT OF NETWORK and the payer is not currently accepting new in network groups at this time. Due to this, credentialing is not required - Stacey Hudak"]
["Evbu O Enakpene, MD",1972816189,"27-4061759","TX","","First Health Coventry","Participating","Enrollment Complete","2023-03-01","","","2023-07-26","07.26.2023 S/W Stacy of First Health @800-226-5116. Per rep, provider is showing participating and link under the Group and TIN with an Effective date 03/01/2023. Provider ID 3658746. Service location is on file. Call ref#:708923. - Danico Gabriel Melendres"]
["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,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicare","Participating","Enrollment Complete","2018-08-01","678418","519061","2020-04-27","04/27/2020 - Confirmed enrollment through PECOS Group enrollment - Stacey Hudak"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Tricare Prime","Participating","Enrollment Complete","2023-10-27","","","2024-02-13","Provider is linked to this Tricare Prime Credentialed location. MS"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2018-07-24","1760860720","","2020-06-26",""]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Rail Road Medicare","Participating","Enrollment Complete","2023-11-01","Q00615984","","2023-12-07","Received enrollment confirmation. MS"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","Triwest VA","Enrollment Stopped","Enrollment Stopped","","","","","Practice is hospital-based; not eligible for TriWest VA enrollment"]
["Jeffrey Hunter Atkins, MD",1760860720,"75-2656723","TX","PE - Premier Family Care, Inc","Superior","Participating","Enrollment Complete","2023-12-01","","","2023-12-08","12/8/2023 Rcvd roster from Superior Health Plan confirming provider is PAR and linked to group TIN/location effective 12/1/2023.  DCannon"]
["Jeffrey Hunter Atkins, MD",1760860720,"47-5554737","TX","PE - Midland Inpatient Medical Association","USA PPO","Participating","Enrollment Complete","2018-07-31","","","2020-09-09","Confirmed provider is participating with PPO and H&W networks (list of networks attached). Kimberly Frazier"]
["Amber J White, PA",1255614970,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","2016-08-02","1255614970","364596201","2023-09-06","Approval letter rcvd from TMHP. Effective 08/02/2016. Jen Videan\n\nAmber White was deactivated with Medicaid, however when she was reactivated there was a gap from 06/07/2023-08/29/2023. Request made to TMHP to have gap removed due to impacted claims. Nichol Carpenter requested a list of impacted claims as well has total amount effected. \n\nMQA decided not to pursue due to so few claims. See attached email. Jen Videan"]
["Amber J White, PA",1255614970,"47-5554737","TX","","Medicaid","Participating","Enrollment Complete","2016-08-02","1255614970","364596201","2023-09-06","Approval letter rcvd from TMHP. Effective 08/02/2016. Jen Videan\n\nAmber White was deactivated with Medicaid, however when she was reactivated there was a gap from 06/07/2023-08/29/2023. Request made to TMHP to have gap removed due to impacted claims. Nichol Carpenter requested a list of impacted claims as well has total amount effected. \n\nMQA decided not to pursue due to so few claims. See attached email. Jen Videan"]
["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","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1255614970","","",""]
["Luis F Hernandez, DO",1447412895,"47-5554737","TX","PE - Midland Inpatient Medical Association","Medicaid","Participating","Enrollment Complete","","202275811","","2020-05-07","05/07/2020 - signed onto MIMA TMHP and was able to verify that this provider is effective with the following networks: \nCommunity Health Choice - Harris, Community Health Choice - Jefferson, TRADITIONAL MEDICAID  - Stacey Hudak"]
["Luis F Hernandez, DO",1447412895,"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"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","TriCare Standard","Participating","Enrollment Complete","2024-01-19","","","2024-02-07","Confirmed provider is enrolled at this location. MS"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","HealthSmart PPO","Participating","Enrollment Complete","2014-09-23","1447406137","","2020-06-05","06/05/2020 - Rec'd email from the payer stating this provider is EFF -Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","Galaxy Health","Participating","Enrollment Complete","2024-01-01","","","2024-05-31","Received email confirmation from Karen Avalos (kavalos@ghn-mic.com) provider is PAR and linked to TIN/locations, eff. 1/1/2024. PA"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Wellcare","Participating","Enrollment Complete","2021-11-01","","","2024-04-29","Per email from Sebastian Flores (sebastian.flores@superiorhealthplan.com), provider is PAR and linked to TIN/location, eff 11/1/2021. PA."]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","HealthSmart PPO","Participating","Enrollment Complete","2024-01-01","","","2024-05-28","Spoke to Yvonne call ref#110778 provider participating with new location as of 1/1/2024. FC"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Cigna","Participating","Enrollment Complete","2019-09-01","8628903","","2020-07-16","7/16/2020 - Rec'd email from the payer stating \"Thank you for your submission. This is to confirm that your request has been completed.\" - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Superior","Participating","Enrollment Complete","2017-01-01","1447406137","","2020-07-14","07/14/2020 - Rec'd email from the payer stating this provider is EFF under PRIMED DELEGATED agreement - Stacey Hudak"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","Boon Chapman","Participating","Enrollment Complete","2018-09-11","1447406137","","2020-10-05","Enrollment thru PHCS"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","Triwest VA","Participating","Enrollment Complete","2022-08-01","","","2022-11-14","11/14/22 Per Scarlett Abigail, provider effective 8/1/22"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","First Health Coventry","Participating","Application Resubmitted","2024-02-13","","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","","Amerigroup","Participating","Enrollment Complete","2018-05-03","","","2021-08-26","8/26/2021 Rcvd full roster from Joe Rodriguez at Amerigroup listing provider as PAR w/ group TIN and location effective 5/3/2018.  DCannon"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","Rail Road Medicare","Participating","Enrollment Complete","2016-01-09","P01708900","DW5495","2024-03-06","Provider is enrolled. MS"]
["Indira Donepudi, MD",1447406137,"81-1031742","TX","PE - Permian Digestive Disease Center PA","IMS","Participating","Enrollment Complete","2019-09-01","1447406137","","2020-07-27","07/27/2020 - Rec'd roster response back from the payer regarding 7/15/2020 submission stating that all requested providers/service locations have been added to PriMed agreement - Stacey Hudak"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","Participating","Enrollment Complete","2024-02-05","","","2024-11-12","Received confirmation via email from Lee Kinard with HealthSmart. Provider participating as of 2/5/2024. AS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-02-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 2/05/2024.  PA"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-02-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 2/05/2024.  PA"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Multiplan","Opt Out","Application Submitted","","","","2024-02-20","2/20/2024- Submitted application via delegated monthly roster on 2/15/2024. FC."]
["John Petersen, MD",1972506442,"47-3465832","TX","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","BCBSTX","Participating","Enrollment Complete","2024-02-06","","","2024-02-05","2/05/2024 - received an email confirmation provider is PAR, eff. 2/06/2024. Provider is PAR with the following networks: \nBAV - Blue Advantage HMO\nBCA - BlueChoice PPO\nHME - Health Select\nHMO - Blue Essentials\nPMC - Medicare Advantage PPO.  -PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","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","Application Resubmitted","2024-02-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","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","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","Participating","Payor Follow Up","","","","2024-07-29","Receivied email confirmation provider is linked to locations. Awaiting effective date confirmation. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","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","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 Contracting","","","","2024-06-18","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","Participating","Enrollment Complete","2024-02-05","","","2024-10-31","Received confirmation via delegated roster provider participating as of 2/5/2024. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Enrollment Complete","2024-03-01","","","2024-06-26","Spoke to Rick P call ref# 1106851 he indicated provider is participating as of 3/1/2024 with all 5 locations. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","Participating","Application Resubmitted","2024-03-01","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-19","","","2024-11-19","11/19/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["John Petersen, MD",1972506442,"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"]
["John Petersen, MD",1972506442,"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"]
["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","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","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["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","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 10/4/2024\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 10/4/2024. AS"]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Amerigroup","Participating","Enrollment Complete","2024-10-04","","","2024-11-11","Received confirmation via delegated roster. Provider participating as follows:\n6301 Andrews Hwy eff. 10/4/2024\n6950 Eastridge Rd &\n 4705 Briarwood Ave eff. 10/4/2024\n3490 E Yukon Rd eff. 8/31/2024\n616 N Main st eff. 10/4/2024. AS"]
["John Petersen, MD",1972506442,"47-3465832","TX","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","Liberty Mutual","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","United Health Care","Participating","Enrollment Complete","2024-02-05","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating , effective 02/05/2024.  PA"]
["John Petersen, MD",1972506442,"47-3465832","TX","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","PPHP","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["John Petersen, MD",1972506442,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD",1972506442,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Wellcare","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["John Petersen, MD",1972506442,"47-3465832","TX","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)","Participating","Enrollment Complete","2024-03-15","","","2024-07-19","Received roster from HP Delegation; provider is PAR and linked to TIN/locations, eff. 03/15/2024. PA."]
["John Petersen, MD",1972506442,"47-3465832","TX","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","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","Application Resubmitted","2024-02-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","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","Application Resubmitted","2024-02-05","","","2024-09-27","Unable to get cofirmation from payor if the previous termination request was stopped, submitted delegated roster via email on 9/27/2024 except Longview location. FC"]
["John Petersen, MD",1972506442,"47-3465832","TX","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","Ambetter","Participating","Enrollment Complete","2024-10-01","","","2024-10-22","Received Oct. SHP validation report: provider listed as par, linked to TIN & locations, effective 10/1/2024."]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","PE - Shylesh Ganta, MD, PA","IMS","Participating","Application Submitted","2019-09-01","1750794749","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","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","","Aetna","Participating","Add Info Submitted","2020-08-01","","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["Tiffany B Hansen, APRN-FNP-BC",1750794749,"20-8658501","TX","","Omni PPO","Participating","Add Info Submitted","2019-09-01","1750794749","","2024-11-14","Submitted recredentialing application via delegated roster. AS"]
["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","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"]
["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","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","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","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","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","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","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","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"]
["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","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"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Medicare","Participating","Enrollment Complete","2024-09-03","7D0212","423838","2024-12-09","Received welcome letter. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-09-30","Emailed roster to brandhi_wilson-woods@corvel.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","In Process","Application Submitted","","","","2024-09-30","Emailed roster to brandhi_wilson-woods@corvel.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","In Process","Application Submitted","","","","2024-09-30","Application submitted via pswca.org. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","In Process","Application Submitted","","","","2024-09-30","Application and required documents emailed to spneast@sedgwickcms.com. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Humana","In Process","Payor Follow Up","","","","2024-11-20","Sent urgent request to payor for an update on enrollment status. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Galaxy Health","In Process","Payor Follow Up","","","","2024-11-12","Requested enrollment status from payor via email. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","2024-10-24","","","2024-11-26","Application submitted for other 4 locations. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","2024-10-24","","","2024-11-26","Application submitted for other 4 locations. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","2024-10-24","","","2024-11-26","Application submitted for other 4 locations. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Wellmed","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","First Health Coventry","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","United Health Care","Participating","Enrollment Complete","2024-10-07","","","2024-11-26","Obtained the product roster from UHC via online portal chat. Provider is listed as participating, eff. 10/07/2024.  PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","HealthSmart PPO","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna","Participating","Enrollment Complete","","","","2024-09-23","This group and Tax ID are already contracted with Cigna via an Ancillary contract agreement.  Therefore, the provider does not require credentialing.  All services rendered by the provider should be billed under the contracted Ancillary Tax ID. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Payor Follow Up","","","","2024-11-21","Sent urgent request to payor for an update on enrollment status. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","TriCare Standard","In Process","Application Submitted","","","","2024-11-26","Application submitted to link to Big Spring location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","","","","2024-11-12","11/12/2024 location added, see other CAQH tab for exp dates pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","IMS","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","CAQH","Participating","CAQH Reattested","2024-11-12","","","2024-11-12","11/12/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Scott&White (First Care)","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Omni PPO","Participating","Enrollment Complete","2024-10-07","","","2024-12-09","Received confirmation from German Aviles via email provider participating effective 10/7/2024. AS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Corvel Healthcare Corp.","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Pending initial enrollment completion. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Cigna Healthspring","Pending Other Enrollment","Pending Contracting","","","","2024-10-02","Pending group enrollment. Request was emailed to TXMAContracting@cignahealthcare.com. If the payor decides to approve the request, they will reach back out with a roster request. The rep stated that follow up is not needed to question status of group enrollment. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","BCBSTX","Participating","Enrollment Complete","2024-10-25","","","2024-11-13","Received enrollment confirmation, provider is par, eff. 10/25/2024, participating with the following networks: Blue Advantage HMO, Blue Choice PPO, Health Select, Blue Essentials, and Medicare Advantage PPO.  PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Broadspire Services Inc.","Participating","Enrollment Complete","","","","2024-10-08","Per updates@primehealthservices.com, provider has been added. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Caprock (CapStar)","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Sedgwick","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Tricare Prime","Panel Closed","Panel Closed","","","","2024-09-19","Panel closed for this location. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","USA PPO","In Process","Application Submitted","","","","2024-10-17","Submitted application via delegated roster on 10/15/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Aetna","In Process","Application Submitted","","","","2024-10-15","Submitted application via delegated roster. FC"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Municipal League","Thru Other Payor","Thru Other Payor","","","","2024-09-30","Please see status under Alliance WC payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Rail Road Medicare","Participating","Enrollment Complete","","","","2024-11-26","There is no enrollment needed to add a new location to the RR MCR record unless you are changing the primary address. MS"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Pending Other Enrollment","Pending Other Enrollment","","","","2024-12-02","Please see status updates under group record payor line. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Alliance WC","Pending Other Enrollment","Pending Other Enrollment","","","","2024-11-12","Pending initial enrollment completion. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Humana","In Process","Application Submitted","","","","2024-10-17","Submitted location add via delegated roster on 10/15/2024. PA"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","PPHP","Participating","Enrollment Complete","2024-10-07","","","2024-12-26","Received email confirmation enrollment complete, eff. 10/07/2024. PA."]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","tx","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Sandra L Orozco, PA",1437650934,"47-3465832","TX","PE - WesTex Urgent Care, PLLC","Texas Mutual","Participating","Enrollment Complete","2024-12-01","","","2024-12-11","Welcome ltr rcvd. Effective 12/01/2024. Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","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","","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","","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","","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","","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","","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","","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","","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","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-10-09","Taxonomy code 207R00000X has been disenrolled. 207RC0200X enrolled, effective 03/22/2024. Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-10-09","Taxonomy code 207R00000X has been disenrolled. 207RC0200X enrolled, effective 03/22/2024. Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-10-09","Taxonomy code 207R00000X has been disenrolled. 207RC0200X enrolled, effective 03/22/2024. Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","","Medicaid","Participating","Enrollment Complete","2024-03-22","","","2024-10-09","Taxonomy code 207R00000X has been disenrolled. 207RC0200X enrolled, effective 03/22/2024. Jen Videan"]
["Saranya Rajasekar, MD",1871028365,"75-2656723","TX","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","","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","","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","","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","","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","","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","","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","","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","","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","","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","","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","","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","","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","","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","","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","","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","","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","","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","","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","","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","","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"]
["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","2024-11-22","13885700","","2024-11-22","11/22/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD",1265872592,"86-3825791","TX","PE - West Texas Ob/Gyn","First Health Coventry","Participating","Enrollment Complete","2020-09-01","","","2024-10-04","Received confirmation providers effective date is 9/1/2020, via email from GFast@aetna.com. FC"]
["Deepika Devalla, MD",1265872592,"47-5554737","TX","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","2024-12-30","","","2024-12-30","12/30/2024 CAQH Reattested all locations current and all expirables up to date pklika"]
["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","","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","HealthSmart PPO","Participating","Application Resubmitted","2017-06-06","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","HealthSmart PPO","Participating","Application Resubmitted","2017-06-06","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","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","","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","First Health Coventry","Participating","Application Resubmitted","2022-12-15","3546231","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","First Health Coventry","Participating","Application Resubmitted","2022-12-15","3546231","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","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","","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","Multiplan","Participating","Application Resubmitted","2020-04-03","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Multiplan","Participating","Application Resubmitted","2020-04-03","","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","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","Aetna","Participating","Enrollment Complete","2020-08-01","","","2024-07-22","As per January roster provider participating as of 8.1.2020 listed as a SPEC. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","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","","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","IMS","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","IMS","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","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","","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","Amerigroup","Participating","Application Resubmitted","2018-04-20","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Amerigroup","Participating","Application Resubmitted","2018-04-20","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Caprock (CapStar)","Participating","Enrollment Complete","2020-03-01","1013456649","","",""]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Caprock (CapStar)","Participating","Application Resubmitted","2020-03-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2020-03-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Ambetter","Participating","Enrollment Complete","2022-04-01","","","2022-06-13","6/13/2022 Received April Monthly Validation roster from Superior and provider is PAR and linked effective 4/1/2022.  DCannon"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","IMS complete"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Omni PPO","Participating","Enrollment Complete","2019-09-01","1013456649","","2020-07-27","IMS complete"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","PE - Midland Inpatient Medical Association","Omni PPO","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Gypsy J Jasso, APRN, FNP-C",1013456649,"47-5554737","TX","","Omni PPO","Participating","Application Resubmitted","2019-09-01","1013456649","","2024-07-22","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","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","","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","Multiplan","Participating","Application Resubmitted","2019-04-05","1396930426","West Texas Physicians Alliance","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Multiplan","Participating","Application Resubmitted","2019-04-05","1396930426","West Texas Physicians Alliance","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","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","","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","Caprock (CapStar)","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Caprock (CapStar)","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","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","","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","Omni PPO","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Omni PPO","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","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","","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","IMS","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","IMS","Participating","Application Resubmitted","2019-05-21","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","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","","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","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","HealthSmart PPO","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","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","","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","Amerigroup","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","","Amerigroup","Participating","Application Resubmitted","2019-05-31","1396930426","","2024-07-18","Submitted reapplication via delegated roster on 7/15/2024. FC"]
["Tzu-Ching Wu, MD",1396930426,"75-2656723","TX","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":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"]